Nokea
A patient with a history of deep vein thrombosis (DVT) is prescribed warfarin therapy. Which instruction is essential for the nurse to include in patient education about warfarin therapy?
- A. "Limit your intake of green leafy vegetables."
- B. "Avoid activities that may increase your risk of bleeding."
- C. "Take a double dose if you miss a dose to catch up."
- D. "Report any unusual bleeding or bruising to your healthcare provider."
Correct Answer: D
Rationale: It is essential for the nurse to instruct the patient to "Report any unusual bleeding or bruising to your healthcare provider." Warfarin is a medication that works by decreasing the clotting ability of the blood. This can increase the risk of bleeding, so it is important for the patient to be vigilant for any signs of abnormal bleeding. Prompt reporting of any unusual bleeding or bruising allows healthcare providers to adjust the dosage of warfarin to maintain a balance between preventing blood clots and minimizing the risk of bleeding complications. This instruction emphasizes the importance of close monitoring and communication with healthcare providers while on warfarin therapy.
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What specific term should Nurse Gladys write in her charting when a patient is suffering from a change in the angle between the nail base greater than 180 degrees due to congenital heart disease?
- A. Peripheral neuropathy
- B. Inflammation of the fingers
- C. Peripheral cyanosis
- D. Clubbing of the fingers
Correct Answer: D
Rationale: Clubbing of the fingers is a specific term that Nurse Gladys should write in her charting when a patient is suffering from a change in the angle between the nail base greater than 180 degrees due to congenital heart disease. Clubbing of the fingers is a diagnostic sign associated with various medical conditions, including congenital heart disease. It is characterized by changes in the angle and shape of the nails, typically involving softening of the nail bed, enlargement of the fingertips, and a loss of the normal angle between the nail and the nail bed. Peripheral neuropathy, inflammation of the fingers, and peripheral cyanosis are different conditions and do not specifically describe the nail changes seen in clubbing.
During a patient consultation, the nurse notices the patient seems anxious and is avoiding eye contact. What is the most appropriate action for the nurse to take?
- A. Continue with the consultation without addressing the patient's behavior.
- B. Ask the patient if they are feeling anxious and if they would like to talk about it.
- C. Ignore the patient's behavior and focus solely on the medical information.
- D. Tell the patient to relax and stop being anxious.
Correct Answer: B
Rationale: The most appropriate action for the nurse to take when noticing that the patient seems anxious and is avoiding eye contact is to ask the patient if they are feeling anxious and if they would like to talk about it. This approach shows empathy, concern, and openness to addressing the patient's emotional state. By directly acknowledging the patient's behavior and giving them the opportunity to express their feelings, the nurse can create a supportive and caring environment that promotes effective communication and trust between the patient and healthcare provider. It is important to consider the patient's emotional well-being alongside their physical health during consultations.
Nurse Nora notices patient's uterine contractions are 70 seconds long and occur every 90 seconds when assessing the frequency of her contractions after she receives oxytocin. what would be the nurse's FIRST action?
- A. Give an emergency bolus of oxytocin to relaxed the uterus
- B. Discontinue the administration of the oxytocin infusion
- C. Increase the rate of client's IV infusion
- D. Ask client to turn to her left side and breathe deeply
Correct Answer: B
Rationale: Patient's uterine contractions lasting 70 seconds and occurring every 90 seconds signify hyperstimulation, which can be a serious complication associated with oxytocin administration. This may result in decreased uterine perfusion, fetal distress, and other adverse effects. The first action should be to discontinue the oxytocin infusion to prevent further complications and allow the uterus to relax. Observations and assessment should continue to monitor the patient's condition and response after discontinuing the infusion. Giving an emergency bolus of oxytocin or increasing the IV infusion rate would exacerbate the hyperstimulation, and turning the client to her left side and breathing deeply would not address the underlying issue of oxytocin-induced hyperstimulation.
A postpartum client who delivered vaginally reports difficulty emptying the bladder completely and experiences urinary frequency. What nursing intervention should be prioritized to address this issue?
- A. Assessing for signs of urinary retention or bladder distention
- B. Encouraging the client to increase fluid intake to promote urination
- C. Recommending the use of warm compresses to the suprapubic area
- D. Teaching the client pelvic floor exercises to improve bladder control
Correct Answer: A
Rationale: The priority nursing intervention in this situation is to first assess the client for signs of urinary retention or bladder distention. Difficulty in emptying the bladder completely and experiencing urinary frequency can be indications of urinary retention, which can lead to bladder distention and possible complications such as urinary tract infection. By assessing the client, the nurse can determine the cause of the issue and implement appropriate interventions. It is crucial to address potential complications promptly to promote the client's health and well-being postpartum. Once the assessment is completed, further interventions such as recommending appropriate measures, like warm compresses or pelvic floor exercises, can be considered based on the assessment findings.
A woman in active labor is diagnosed with uterine rupture, resulting in fetal distress and maternal hemorrhage. What nursing intervention is essential in managing this obstetric emergency?
- A. Initiating immediate oxytocin infusion
- B. Preparing for immediate instrumental delivery
- C. Performing an emergency cesarean section
- D. Administering intravenous magnesium sulfate
Correct Answer: C
Rationale: Uterine rupture is a severe obstetric complication that requires prompt and decisive management to prevent adverse outcomes for both the mother and the baby. In cases of uterine rupture leading to fetal distress and maternal hemorrhage, performing an emergency cesarean section is crucial. This intervention allows for rapid delivery of the baby, relieving the distress on the fetus and enabling immediate access to manage the maternal hemorrhage. By performing a timely cesarean section, healthcare providers can expedite the delivery process and effectively address both the fetal and maternal complications associated with uterine rupture. This intervention is essential in saving lives and reducing the risk of further complications in such a critical obstetric emergency.