What are the priority actions of the nurse who enters the patient’s room to begin teaching the patient about wound care management and notes that the patient is nauseated due to medication side effects? (Select all that apply).

Check the patient’s order list to determine if antiemetic medication has been prescribed for the patient.

Begin teaching the patient about wound care management, taking care to avoid using terms that the patient might find upsetting.

Provide measures to relieve the patient’s nausea and return to teach about wound care when the patient is feeling better.

Apply a cold cloth to the patient's forehead and maintain a quiet odor-free environment for the patient.

Document in the patient’s chart that teaching about wound care management was not done because the patient refused to learn.

Answer and Explanation

Correct Answer : A,C

Choice A reason: This is a correct choice because checking the patient’s order list to determine if antiemetic medication has been prescribed for the patient is a priority action of the nurse who notes that the patient is nauseated due to medication side effects. This action is important to manage the patient's nausea and prevent vomiting, which can lead to dehydration, electrolyte imbalance, and aspiration. The nurse should follow the physician's orders and administer the antiemetic medication as indicated.

Choice B reason: This is an incorrect choice because beginning teaching the patient about wound care management, taking care to avoid using terms that the patient might find upsetting, is not a priority action of the nurse who notes that the patient is nauseated due to medication side effects. This action is not appropriate to perform when the patient is feeling sick and uncomfortable, as it may impair the patient's learning ability and motivation. The nurse should postpone the teaching until the patient's nausea is resolved and the patient is ready to learn.

Choice C reason: This is a correct choice because providing measures to relieve the patient’s nausea and returning to teach about wound care when the patient is feeling better is a priority action of the nurse who notes that the patient is nauseated due to medication side effects. This action is essential to address the patient's immediate need and comfort, and to ensure that the patient receives the necessary education about wound care management at a suitable time. The nurse should provide measures such as offering clear liquids, crackers, or ginger, positioning the patient in a semi-Fowler's position, and providing a basin or emesis bag if needed.

Choice D reason: This is an incorrect choice because applying a cold cloth to the patient's forehead and maintaining a quiet odor-free environment for the patient is not a priority action of the nurse who notes that the patient is nauseated due to medication side effects. This action is a supportive measure that may help to soothe the patient's nausea, but it is not sufficient to treat the underlying cause or prevent further complications. The nurse should also check the patient's order list and administer the antiemetic medication if prescribed.

Choice E reason: This is an incorrect choice because documenting in the patient’s chart that teaching about wound care management was not done because the patient refused to learn is not a priority action of the nurse who notes that the patient is nauseated due to medication side effects. This action is a false and inaccurate documentation that does not reflect the patient's condition or the nurse's actions. The nurse should document the patient's nausea, the interventions provided, and the plan to resume the teaching when the patient is feeling better.

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Correct Answer is A

Explanation

Choice A reason: This is correct. The patient must hold on to the railing when ambulating in the hallway indicates that the patient is experiencing difficulty with proprioception. Proprioception is the body's ability to sense its own position, movement, and spatial orientation. It helps the patient maintain balance and coordination. If the patient has impaired proprioception, they may feel unsteady or fall when walking without support.

Choice B reason: This is incorrect. The patient must add extra seasoning to food in order for it to have any flavor does not indicate that the patient is experiencing difficulty with proprioception. This may indicate that the patient has a reduced sense of taste, which can be caused by various factors, such as aging, medication, infection, or smoking. It does not affect the patient's perception of their body or movement.

Choice C reason: This is incorrect. The patient suffered a first-degree burn when a heating pad was left on too long does not indicate that the patient is experiencing difficulty with proprioception. This may indicate that the patient has a reduced sense of pain or temperature, which can be caused by nerve damage, diabetes, or spinal cord injury. It does not affect the patient's perception of their body or movement.

Choice D reason: This is incorrect. The patient did not smell smoke even though the smoke detector was alarming does not indicate that the patient is experiencing difficulty with proprioception. This may indicate that the patient has a reduced sense of smell, which can be caused by nasal congestion, allergy, infection, or head injury. It does not affect the patient's perception of their body or movement.

A. Apical B. Carotid C. Radial D. Brachial

Correct Answer is A

Explanation

Choice A reason: This is the correct choice because the apical pulse is the most accurate measurement of the heart rate and rhythm. Digoxin is a cardiac medication that affects the heart rate and can cause arrhythmias. Therefore, the nurse should use the apical pulse to monitor the patient's response to the medication.

Choice B reason: This is an incorrect choice because the carotid pulse is not the best site to measure the heart rate before administering digoxin. The carotid pulse is located in the neck and can be affected by external factors such as pressure or movement. The carotid pulse is also not recommended for routine use because it can stimulate the vagus nerve and lower the heart rate.

Choice C reason: This is an incorrect choice because the radial pulse is not the best site to measure the heart rate before administering digoxin. The radial pulse is located in the wrist and can be affected by peripheral factors such as circulation or temperature. The radial pulse can also be inaccurate or irregular if the patient has an arrhythmia.

Choice D reason: This is an incorrect choice because the brachial pulse is not the best site to measure the heart rate before administering digoxin. The brachial pulse is located in the upper arm and can be affected by arm position or blood pressure. The brachial pulse is also not as reliable as the apical pulse for detecting changes in the heart rate and rhythm.

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What are the priority actions of the nurse who enters the patient’s room to begin teaching the patient about wound care management and notes that the patient is nauseated due to medication side effects? (Select all that apply).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which assessment finding indicates to the nurse that the patient is experiencing difficulty with proprioception?

Correct Answer is A

Explanation

Which site will the nurse use to measure the patient’s pulse rate before administering the cardiac medication Digoxin?

Correct Answer is A

Explanation

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