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A postpartum client presents with sudden, severe chest pain and dyspnea. Which nursing action is most appropriate?
- A. Placing the client in a semi-Fowler's position
- B. Administering supplemental oxygen therapy
- C. Notifying the healthcare provider immediately
- D. Encouraging the client to perform deep breathing exercises
Correct Answer: C
Rationale: Sudden, severe chest pain and dyspnea in a postpartum client could be indicative of a potential serious condition, such as a pulmonary embolism or postpartum cardiomyopathy, which require immediate medical attention. Therefore, the most appropriate nursing action would be to notify the healthcare provider immediately for further evaluation and management. Placing the client in a semi-Fowler's position may provide some comfort but does not address the underlying cause of the symptoms. Administering supplemental oxygen therapy may be necessary once the healthcare provider assesses the client. Encouraging deep breathing exercises may not be appropriate if the client is experiencing severe chest pain and dyspnea, as it could worsen the situation.
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A patient presents with a thyroid nodule and signs of hyperthyroidism. Fine-needle aspiration biopsy reveals Hurthle cells and cellular atypia. Which endocrine disorder is most likely responsible for these symptoms?
- A. Hashimoto's thyroiditis
- B. Graves' disease
- C. Hurthle cell carcinoma
- D. Papillary thyroid carcinoma
Correct Answer: C
Rationale: Hurthle cell carcinoma is a type of thyroid cancer that arises from the Hurthle cells of the thyroid gland. Patients with Hurthle cell carcinoma may present with a thyroid nodule and signs of hyperthyroidism, which can mimic other thyroid disorders such as Graves' disease. Fine-needle aspiration biopsy revealing Hurthle cells and cellular atypia is suggestive of a Hurthle cell neoplasm, particularly Hurthle cell carcinoma. It is important to differentiate Hurthle cell carcinoma from benign Hurthle cell adenomas or other thyroid conditions to guide appropriate management and treatment.
A 32-year-old pregnant woman presents with painless vaginal bleeding at 10 weeks of gestation. On ultrasound, a gestational sac with no embryo is visualized within the uterus. Which of the following conditions is most likely to be responsible for these findings?
- A. Threatened abortion
- B. Inevitable abortion
- C. Missed abortion
- D. Ectopic pregnancy
Correct Answer: C
Rationale: In a missed abortion, the embryo has died, but the products of conception remain in the uterus, leading to the visualization of a gestational sac without an embryo on ultrasound. This is a type of missed miscarriage where the woman may not have any symptoms initially and the diagnosis is made during a routine ultrasound. The most common presenting symptom is painless vaginal bleeding. The absence of an embryo within the gestational sac can be confirmed through serial ultrasound examinations showing no fetal growth or cardiac activity. It is important for healthcare providers to provide appropriate counseling and management options to support the patient through this emotional experience.
While preparing the operating room (OR) for a surgical procedure, the nurse notices that the surgical instrument tray is incomplete. What should the nurse do?
- A. Proceed with the procedure using the available instruments
- B. Document the missing instruments in the surgical count log
- C. Inform the sterile processing department and request additional instruments
- D. Borrow the missing instruments from another OR Professionalism and Fundamentals of Nursing
Correct Answer: C
Rationale: It is crucial to have a complete set of surgical instruments for any surgical procedure to ensure patient safety and the success of the surgery. If the nurse notices that the surgical instrument tray is incomplete, the best course of action is to inform the sterile processing department immediately. By doing so, the missing instruments can be promptly provided, ensuring that the surgical team has all the necessary tools for the procedure. Proceeding with the procedure using incomplete instruments can compromise patient safety and the quality of care provided. Documenting the missing instruments in the surgical count log is important for record-keeping purposes but should not delay the immediate action of requesting additional instruments. Borrowing instruments from another OR is not recommended as it can create confusion, potential cross-contamination, and disrupt the workflow of another surgical team.
A patient with advanced dementia is bedbound and at risk of developing pressure ulcers. What intervention should the palliative nurse prioritize to prevent pressure ulcer formation?
- A. Turn the patient every 2 hours to relieve pressure on bony prominences.
- B. Apply barrier creams or moisture barriers to protect vulnerable skin areas.
- C. Use pressure-relieving support surfaces, such as specialized mattresses or cushions.
- D. Administer prophylactic antibiotics to prevent infection in at-risk skin areas.
Correct Answer: C
Rationale: The most effective intervention to prevent pressure ulcers in bedbound patients at risk, such as those with advanced dementia, is to use pressure-relieving support surfaces like specialized mattresses or cushions. These surfaces help distribute the pressure evenly, reducing the risk of pressure ulcer formation on bony prominences. Turning the patient every 2 hours (choice A) can also help relieve pressure, but it may not be sufficient to prevent pressure ulcers in high-risk individuals. Applying barrier creams or moisture barriers (choice B) can help protect the skin but may not address the underlying issue of pressure on vulnerable areas. Administering prophylactic antibiotics (choice D) is not recommended for preventing pressure ulcers as it does not address the root cause of the problem and can lead to antibiotic resistance. Therefore, the priority intervention should be to use pressure-relieving support surfaces to minimize the risk of pressure ulcers in
A postpartum client who delivered vaginally expresses concern about feeling "heavy" in the perineal area. What education should the nurse provide to address this sensation?
- A. Encourage the client to perform Kegel exercises regularly.
- B. Recommend the use of perineal pads for additional support.
- C. Educate the client about the process of uterine involution.
- D. Suggest the use of a perineal support garment.
Correct Answer: A
Rationale: The sensation of feeling "heavy" in the perineal area postpartum is a common concern due to the stretching and potential trauma to the perineal muscles during childbirth. Kegel exercises are specifically designed to strengthen the pelvic floor muscles, which can help alleviate this sensation of heaviness. By encouraging the client to perform Kegel exercises regularly, the nurse is promoting the restoration and strengthening of the perineal muscles, ultimately helping the client feel more comfortable and supported in that area. This education empowers the client to take an active role in their own recovery and promotes optimal healing postpartum.