Nokea
A postpartum client complains of persistent, heavy vaginal bleeding beyond the expected timeframe. Which nursing action is most appropriate?
- A. Encouraging the client to increase fluid intake
- B. Applying a cold compress to the perineum
- C. Assessing vital signs and uterine tone
- D. Administering pain medication as ordered
Correct Answer: C
Rationale: In a postpartum client complaining of persistent, heavy vaginal bleeding, the most appropriate nursing action is to assess vital signs and uterine tone. This is important to determine if the bleeding is within normal limits or if there is a potential postpartum hemorrhage (PPH) occurring. Monitoring vital signs can help identify signs of shock, while assessing uterine tone can help determine if the uterus is contracting effectively to control bleeding. Prompt assessment and early detection of PPH are crucial for effective management and prevention of complications. Encouraging increased fluid intake, applying a cold compress, and administering pain medication may be appropriate interventions in some situations, but assessing vital signs and uterine tone take priority in this scenario.
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During surgery, the nurse observes a sudden change in the patient's level of consciousness. What is the nurse's immediate action?
- A. Administer a reversal agent for anesthesia
- B. Document the change in the patient's chart
- C. Check the patient's vital signs
- D. Notify the anesthesia provider immediately
Correct Answer: D
Rationale: The correct immediate action for the nurse is to notify the anesthesia provider immediately (Option D). This is crucial because a sudden change in the patient's level of consciousness during surgery could indicate a serious issue related to anesthesia administration. Notifying the anesthesia provider promptly allows for quick assessment and intervention to address the underlying cause, potentially preventing complications or even saving the patient's life. Administering a reversal agent (Option A) without proper evaluation by the anesthesia provider could be dangerous. Documenting the change in the patient's chart (Option B) is important but not the most immediate action. Checking the patient's vital signs (Option C) is also important but may not provide immediate insight into the cause of the change in consciousness.
Which is the simple meaning of standards of nursing care?
- A. What protects the nurse
- B. How the nurse will behave
- C. How much work is done
- D. Ask the local offficials
Correct Answer: B
Rationale: The correct answer is B: How the nurse will behave. Standards of nursing care refer to the expected behaviors and practices that nurses should adhere to in providing quality care to patients. This encompasses ethical principles, professional conduct, and best practices in nursing. It is essential for nurses to follow these standards to ensure patient safety and quality outcomes.
Explanation:
- A: What protects the nurse. This choice is incorrect because standards of nursing care primarily focus on patient care and outcomes, rather than protecting the nurse.
- C: How much work is done. This choice is incorrect as it does not directly relate to the behaviors and practices expected of nurses in providing quality care.
- D: Ask the local officials. This choice is unrelated to the concept of standards of nursing care and is not relevant to the question.
A nurse is conducting an admission assessment for a newly admitted patient. What aspect of cultural competence should the nurse prioritize during the assessment?
- A. Assuming that the patient shares the nurse's cultural beliefs
- B. Asking the patient about their cultural background and preferences
- C. Avoiding discussions about cultural differences to prevent discomfort
- D. Disregarding the patient's cultural practices and beliefs
Correct Answer: B
Rationale: Correct Answer: B
Rationale:
1. Asking the patient about their cultural background and preferences shows respect for their individuality and acknowledges the importance of cultural competence in providing person-centered care.
2. It allows the nurse to gain valuable insights into the patient's beliefs, values, and practices, enabling them to deliver culturally appropriate care.
3. By prioritizing this aspect, the nurse can establish rapport, build trust, and enhance communication with the patient, leading to better outcomes.
4. Choices A, C, and D are incorrect as they either involve assumptions, avoidance, or disregard for the patient's cultural background, which can lead to misunderstandings, discomfort, and ineffective care.
A patient that had a stroke is experiencing memory loss and impaired learning capacity. In which lobe does the nurse determine that brain damage has MOST likely occurred?
- A. Frontal
- B. Parietal
- C. Occipital
- D. Temporal
Correct Answer: D
Rationale: The correct answer is D: Temporal lobe. Memory and learning are primarily associated with the temporal lobe, specifically the hippocampus. Damage to this area due to stroke can lead to memory loss and impaired learning capacity. Frontal lobe (A) is involved in decision-making and problem-solving. Parietal lobe (B) is responsible for sensory processing. Occipital lobe (C) is related to visual processing. Therefore, the temporal lobe is the most likely site of brain damage in this scenario based on the symptoms presented.
A 20-year-old woman presents with sudden onset of severe lower abdominal pain and missed menstrual periods for the past two months. She has a positive urine pregnancy test. On transvaginal ultrasound, an empty uterus is visualized, and there is fluid in the cul-de-sac. Which condition is most likely to be responsible for these findings?
- A. Ovarian cyst rupture
- B. Ectopic pregnancy
- C. Septic abortion
- D. Ovarian torsion
Correct Answer: B
Rationale: The correct answer is B: Ectopic pregnancy. In this scenario, the combination of missed periods, positive pregnancy test, and empty uterus on ultrasound with fluid in the cul-de-sac is highly suggestive of an ectopic pregnancy. Ectopic pregnancy occurs when the fertilized egg implants outside the uterus, commonly in the fallopian tube. The presence of fluid in the cul-de-sac indicates possible blood from a ruptured ectopic pregnancy, causing the severe lower abdominal pain. Ovarian cyst rupture (A) typically presents with less severe pain. Septic abortion (C) would present with signs of infection and products of conception in the uterus. Ovarian torsion (D) would present with acute onset of unilateral lower abdominal pain and a palpable adnexal mass, not fluid in the cul-de-sac.