Nokea
A nurse is preparing to perform a bladder catheterization for a patient with urinary retention. What action should the nurse prioritize to minimize the risk of infection?
- A. Using sterile gloves and a surgical mask during catheterization
- B. Cleansing the perineal area with povidone-iodine solution before catheter insertion
- C. Administering prophylactic antibiotics before the catheterization procedure
- D. Using aseptic technique and sterile equipment during catheter insertion
Correct Answer: D
Rationale: Using aseptic technique and sterile equipment during catheter insertion is crucial for minimizing the risk of infection during bladder catheterization. Aseptic technique involves maintaining a sterile field, washing hands thoroughly, using sterile gloves, and ensuring that all equipment used is sterile. By following these practices, the nurse can prevent introducing bacteria into the urinary tract, reducing the likelihood of infection in the patient. While cleansing the perineal area with antiseptic solutions is important for general hygiene, the priority for infection prevention during catheterization lies in maintaining a sterile environment during the procedure. Administering prophylactic antibiotics is not routinely recommended for catheterization unless there are specific risk factors present.
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One evening, Sonny complained of dyspnea despite continuous oxygen therapy. What should be the FIRST action of the nurse?
- A. Reassess the client.
- B. Give PRN medication.
- C. Assess the patency of the tubing.
- D. Refer client to the physician.
Correct Answer: A
Rationale: The FIRST action of the nurse should be to reassess the client experiencing dyspnea despite continuous oxygen therapy. Reassessment would involve checking the client's respiratory status, oxygen saturation levels, vital signs, and overall condition to gather more information about the situation. This will help the nurse identify any potential causes of the dyspnea and determine the appropriate next steps for intervention. Assessing the client before proceeding with any other actions is crucial in providing safe and effective care.
If transient discoloration of Baby Sharon's skin is noted while under phototherapy, what is this phenomenon called?
- A. Cyanosis
- B. Hyperbilirubinemia
- C. Jaundice
- D. Bronze baby syndrome
Correct Answer: D
Rationale: Bronze baby syndrome is the term used to describe the transient discoloration of a baby's skin while undergoing phototherapy treatment for jaundice. This phenomenon typically occurs in preterm infants and is believed to be caused by the breakdown of bilirubin into colored pigments during phototherapy. The discoloration can range from a bronze or brownish color to a grayish-green hue. One key characteristic of bronze baby syndrome is that the discoloration is reversible once phototherapy is complete and does not indicate any underlying health concerns. It is important for healthcare providers to be aware of this phenomenon to avoid unnecessary interventions or alarm to the caregivers.
Elmo asks the nurse to explain his condition (BPH) Which statements are CORRECT explanations by the nurse? I It blocks the urethra. II It obstructs the bladder. III. It spreads to other parts of the body. IV. It leads to urinary retention
- A. I and IV
- B. I, II and III
- C. II, III, and IV
- D. I and III
Correct Answer: A
Rationale: I. It blocks the urethra: Benign Prostatic Hyperplasia (BPH) is a condition in which the prostate gland enlarges and can squeeze the urethra, leading to urinary symptoms such as difficulty urinating. This statement correctly explains one of the effects of BPH on the urinary system.
A nurse is caring for a patient who expresses concerns about the potential side effects of a prescribed medication. What action should the nurse take to address the patient's concerns?
- A. Disregard the patient's concerns and reassure them about the medication's safety
- B. Provide accurate information about the medication, including potential side effects
- C. Encourage the patient to stop taking the medication if they are worried about side effects
- D. Minimize the importance of the patient's concerns and focus on other aspects of care
Correct Answer: B
Rationale: The nurse should provide accurate information about the medication, including potential side effects, to address the patient's concerns. It is important for the nurse to listen to the patient's worries and provide them with the knowledge they need to make an informed decision about their treatment. By educating the patient about the medication and its potential side effects, the nurse empowers the patient to be actively involved in their care and promotes shared decision-making. Disregarding the patient's concerns, encouraging them to stop taking the medication, or minimizing the importance of their worries are not appropriate responses and may negatively impact the patient-nurse relationship and the patient's adherence to the prescribed treatment.
To remove the ingested poisonous substance, the physician ordered a gastric lavage. What is the role of the nurse immediately prior to the procedure?
- A. Get the right size of the nasogastric tube
- B. Remind parents to be careful next time
- C. Obtain an informed consent immediately
- D. Tell the parent that they are negligent
Correct Answer: A
Rationale: Prior to a gastric lavage procedure, it is essential for the nurse to ensure the correct size of the nasogastric tube is selected. The appropriate size of the tube will allow for effective removal of the ingested poisonous substance during the procedure. Proper sizing also helps in preventing complications such as injury to the gastrointestinal tract or inadequate removal of the substance. This step is crucial for the safe and successful completion of gastric lavage. Reminding parents to be careful, obtaining informed consent immediately, or accusing them of negligence are not immediate responsibilities of the nurse in this context.