Nokea
A postpartum client presents with calf pain, swelling, and warmth. Which nursing action is most appropriate?
- A. Applying a warm compress to the affected calf
- B. Encouraging ambulation to promote circulation
- C. Notifying the healthcare provider immediately
- D. Administering a nonsteroidal anti-inflammatory drug (NSAID) for pain relief
Correct Answer: C
Rationale: The most appropriate nursing action in this scenario is to notify the healthcare provider immediately. The client's presentation of calf pain, swelling, and warmth could be indicative of a deep vein thrombosis (DVT), which is a serious condition that requires prompt evaluation and intervention by the healthcare provider. DVT is a blood clot that forms in a deep vein, often in the leg, and if left untreated, it can lead to life-threatening complications such as pulmonary embolism. Therefore, timely communication with the healthcare provider is critical to ensure that the client receives the appropriate diagnostic testing and treatment to address the potential DVT. Applying warm compresses, encouraging ambulation, or administering NSAIDs would not be the first-line interventions for a suspected DVT and may even worsen the condition.
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During a patient assessment, the nurse observes signs of distress and discomfort. What action should the nurse take to address the patient's needs?
- A. Ignoring the patient's distress to avoid making them uncomfortable
- B. Documenting the findings and informing the healthcare provider later
- C. Offering emotional support and actively listening to the patient's concerns
- D. Administering pain medication without further assessment
Correct Answer: C
Rationale: The correct action for the nurse to take when observing signs of distress and discomfort in a patient during assessment is to offer emotional support and actively listen to the patient's concerns. Ignoring the patient's distress may lead to worsening of the patient's condition and can be detrimental to the patient's well-being. Documenting the findings and informing the healthcare provider later is important but should not be the immediate response when a patient is in distress. Administering pain medication without further assessment is also not appropriate as the nurse needs to understand the underlying cause of the distress before providing appropriate interventions. Offering emotional support and actively listening to the patient's concerns can help the nurse understand the patient's needs, provide comfort, and potentially address the root cause of the distress.
In the universal health law, which of the following are the government agencies that are considered as "key players" in its implementation?
- A. Family, DOH and Philhealth
- B. DOH, LGU and Philippine Health Insurance, Inc. (PhilHealth)
- C. Community, DOH, LGU
- D. Individual, DOH and LGU
Correct Answer: B
Rationale: In the universal health law, the government agencies that are considered as "key players" in its implementation are the Department of Health (DOH), Local Government Units (LGUs), and the Philippine Health Insurance Corporation (PhilHealth).
Friendly but professional overtures have finally made Marlene open up her circumstances to the nurse, including their financial difficulty. What has been established at this time?
- A. Beginning of a friendship
- B. Trusting relationship with the nurse
- C. A lifelong commitment
- D. A dire need for financial help
Correct Answer: B
Rationale: Marlene opening up to the nurse about their financial difficulty indicates that she feels comfortable enough to share personal information with the nurse. This signals the establishment of a trusting relationship between Marlene and the nurse, as Marlene feels safe and supported enough to disclose sensitive information. Building trust is a crucial aspect of any professional relationship, especially in healthcare settings, as it fosters open communication, encourages honesty, and ultimately leads to better outcomes for the patient. It is an essential foundation for providing effective care and support to individuals in need.
What IMMEDIATE danger should the nurse anticipate post Transurethral Resection of the Prostate (TURP)?
- A. Infection
- B. Thrombosis
- C. Bleeding
- D. Shock
Correct Answer: C
Rationale: Post Transurethral Resection of the Prostate (TURP), the immediate danger that the nurse should anticipate is bleeding. TURP is a surgical procedure that involves removing portions of the prostate gland through the urethra. Due to the nature of the surgery and the rich blood supply to the prostate, bleeding is a common complication post-TURP. Excessive bleeding can lead to hypovolemic shock, which is a life-threatening condition. Therefore, monitoring for signs of bleeding, such as blood in the urine, drop in hematocrit levels, hypotension, tachycardia, and signs of hypovolemic shock, is crucial to prevent any serious complications. Proper assessment, monitoring, and timely intervention are essential in managing post-TURP bleeding and preventing adverse outcomes.
A patient with a history of chronic obstructive pulmonary disease (COPD) is prescribed tiotropium (Spiriva) inhaler. Which instruction should the nurse include in patient education about tiotropium inhaler use?
- A. "Use the inhaler only when you experience symptoms."
- B. "Rinse your mouth with water after each use."
- C. "Exhale forcefully before inhaling the medication."
- D. "Store the inhaler in the refrigerator between uses."
Correct Answer: B
Rationale: Tiotropium (Spiriva) is an anticholinergic bronchodilator used for the management of COPD. A common side effect of anticholinergic medications is dry mouth. Rinsing the mouth with water after using the inhaler can help reduce the risk of developing oral thrush or other mouth infections due to dryness. This instruction helps promote good oral hygiene and decreases the potential side effects associated with tiotropium inhaler use. This teaching is important for patients to follow to ensure their overall health and well-being while using the medication.