Nokea
The nursing team plans to do chart audit project on post-op patients who and developed pressure sores at the Orthopedic unit over the past year to present. What type of audit is?
- A. Retrospective
- B. Concurrent
- C. Process
- D. Outcome
Correct Answer: A
Rationale: A retrospective audit involves reviewing past cases or data to evaluate processes, outcomes, or compliance with standards. In this scenario, the nursing team plans to audit post-op patients who developed pressure sores over the past year at the Orthopedic unit. By looking at historical data from the past year, the audit is considered retrospective as it assesses what has occurred over a specified period. This type of audit helps identify trends, patterns, and areas for improvement based on past events.
You may also like to solve these questions
After five days of hospitalization, the physician said Mr. Steeve can be discharged. He ordered medications to be taken at home. The client is still weak and symptomatic, which of the following rights could be violated in this case? Right to _______.
- A. Know hospital rules
- B. Refuse treatment
- C. Privacy
- D. Continuity of care
Correct Answer: B
Rationale: The right to refuse treatment is a fundamental patient right. In this case, the physician ordering medications for the client to take at home without the client's input or agreement could possibly violate the client's right to refuse treatment. It is important for patients to have the autonomy to make decisions regarding their own treatment, especially when they are still weak and symptomatic. Patients should have the opportunity to discuss their treatment plan with their healthcare provider and express any concerns or preferences they may have.
A pregnant woman presents with sudden onset of severe abdominal pain and vaginal bleeding. On examination, her abdomen is rigid, and fetal parts are palpable abdominally. Which of the following conditions is the most likely cause of these symptoms?
- A. Ectopic pregnancy
- B. Pelvic inflammatory disease
- C. Uterine rupture
- D. Ovarian torsion
Correct Answer: C
Rationale: Uterine rupture is the most likely cause of these symptoms in a pregnant woman presenting with sudden onset of severe abdominal pain, vaginal bleeding, rigidity of the abdomen, and palpable fetal parts abdominally. Uterine rupture is a rare but serious complication of pregnancy, typically occurring during labor in women with a previous cesarean delivery or other uterine scars. The sudden onset of severe abdominal pain can be associated with vaginal bleeding due to the tearing of the uterine wall, causing fetal parts to be palpable abdominally. This is a life-threatening emergency that requires immediate medical intervention. Ectopic pregnancy, pelvic inflammatory disease, and ovarian torsion may present with abdominal pain and vaginal bleeding but would not typically present with palpable fetal parts abdominally in a pregnant woman.
Nurse Emma advised the patient to quit smoking because nicotine wil1 contribute to _______.
- A. low birth weight infant
- B. ectopic tubal, pregnancy
- C. congenital anomalies
- D. large for gestation age infants
Correct Answer: A
Rationale: Nicotine, a substance found in cigarettes, is known to have harmful effects on pregnancy. Smoking during pregnancy can lead to numerous complications, one of which is the increased risk of delivering a low birth weight infant. Low birth weight infants are born weighing less than 5.5 pounds (2.5 kilograms) and are at a higher risk of various health issues, developmental delays, and even mortality. Therefore, Nurse Emma advised the patient to quit smoking to reduce the risk of having a low birth weight infant.
A woman in active labor demonstrates signs of cephalopelvic disproportion (CPD), with the fetal head failing to descend despite strong contractions. What nursing action should be prioritized to address this abnormal labor presentation?
- A. Perform a pelvic exam to assess for CPD.
- B. Assist the mother into a hands-and-knees position.
- C. Administer intravenous oxytocin to augment contractions.
- D. Prepare for immediate instrumental delivery.
Correct Answer: D
Rationale: When a woman in active labor demonstrates signs of cephalopelvic disproportion (CPD) with the fetal head failing to descend despite strong contractions, the nursing action that should be prioritized is to prepare for immediate instrumental delivery. CPD can lead to a prolonged and difficult labor, increasing the risks for both the mother and the fetus. In cases where the fetal head is not descending adequately and the mother's contractions are strong, instrumental delivery, like forceps or vacuum extraction, may be necessary to facilitate the safe delivery of the baby. It is important to act promptly to avoid potential complications associated with prolonged labor. Other actions, such as performing a pelvic exam, changing maternal positions, or administering oxytocin, may be considered but addressing the issue of CPD efficiently through instrumental delivery should take precedence in this scenario.
A postpartum client who experienced a third-degree perineal laceration expresses concerns about the healing process and potential complications. What nursing intervention should be prioritized to promote optimal wound healing?
- A. Providing perineal care using peri-bottles with warm water
- B. Instructing the client on proper peri-pad application to the incision
- C. Encouraging the use of sitz baths for pain relief and wound cleansing
- D. Monitoring the incision site for signs of infection or dehiscence
Correct Answer: D
Rationale: Third-degree perineal lacerations are significant injuries that require careful monitoring for signs of infection or wound dehiscence, which are potential complications that could hinder optimal wound healing. Signs of infection may include increased redness, warmth, swelling, pain, and purulent drainage from the wound site. Dehiscence refers to the separation of the wound edges, which can be a serious complication requiring immediate attention. By closely monitoring the incision site for these signs, the nurse can promptly intervene if any complications arise, ensuring proper healing and preventing further complications. While providing perineal care, proper application of peri-pads, and encouraging sitz baths are important for comfort and cleanliness, monitoring for complications takes priority in promoting optimal wound healing in this scenario.