A postpartum client presents with persistent, severe abdominal pain, distention, and absent bowel sounds. Which nursing action is most appropriate?
- A. Encouraging the client to ambulate to promote bowel function
- B. Providing a heating pad to alleviate abdominal discomfort
- C. Notifying the healthcare provider immediately
- D. Administering a laxative to promote bowel evacuation
Correct Answer: C
Rationale: The most appropriate nursing action in this situation is to notify the healthcare provider immediately. The symptoms the postpartum client is experiencing - persistent, severe abdominal pain, distention, and absent bowel sounds - are concerning and could indicate a serious underlying issue such as bowel obstruction or other complications. Prompt communication with the healthcare provider is crucial to ensure the client receives the necessary assessment, intervention, and treatment. Encouraging ambulation, providing a heating pad, or administering a laxative are not appropriate actions in this case without first consulting with the healthcare provider due to the severity and potential complexity of the client's symptoms.
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The nurse is conducting an assessment to her patient who has edema of the lower extremities due to congestive heart failure. If edema is graded on a scale of +1 (no visible edema in the leg) to 4+ (leg very swollen), what will the Nurse document in her chart if her assessment findings of the edema is SLIGHTLY swollen?
- A. 4
- B. 2
- C. 1
- D. 3
Correct Answer: B
Rationale: In the grading system used for edema, +1 indicates no visible edema in the leg, +2 indicates slight edema with indentations that quickly resolve, +3 indicates moderate edema with deeper indentations that may take longer to resolve, and +4 indicates severe edema with very swollen legs. In this case, since the edema is described as slightly swollen, the appropriate grade to document would be +2.
As a nurse you are guided that pain is usually described BEST as a phenomenon which is a ________.
- A. Neurologic activation nociceptors
- B. Subjective unpleasant experience
- C. Adaptive mechanism to a stimulus
- D. Creation of one's imagination
Correct Answer: B
Rationale: Pain is best described as a subjective unpleasant experience because it is unique to each individual and is influenced by a variety of factors including emotional, psychological, and cultural elements. Pain cannot be objectively measured or quantified, and therefore it is considered a subjective experience that is reported by the person experiencing it. This is why pain is often assessed using self-report scales and tools to capture the individual's perception of their pain intensity and quality.
Which law declares that the policy of the State is to promote and upgrade the practice of profession in the country?
- A. RA 7164
- B. Code of Ethics
- C. RA 9173
- D. RA 10912
Correct Answer: C
Rationale: RA 9173, also known as the Philippine Nursing Act of 2002, is the law that declares the State policy to promote and upgrade the practice of the nursing profession in the Philippines. This law provides for the regulation and maintenance of high standards of nursing education and practice in the country. It aims to ensure the welfare and professional growth of Filipino nurses and to safeguard the health of the public by maintaining competency and professionalism in the nursing profession. Therefore, RA 9173 is the correct choice that reflects the State's policy to promote and upgrade the practice of the nursing profession in the Philippines.
The labor progress and the physician performed amniotomy. Nurse Hope should FIRST assess tor _______.
- A. bladder distention
- B. maternal blood pressure
- C. cervical dilatation
- D. fetal heart rate (FHR) pattern
Correct Answer: D
Rationale: Following an amniotomy procedure during labor, Nurse Hope's priority should be to assess the fetal heart rate (FHR) pattern. This assessment is crucial to ensure the well-being and safety of the fetus. Changes in the FHR can provide valuable information about fetal distress or complications, allowing for timely interventions if needed. Monitoring the FHR pattern is a standard practice during labor and delivery to track the fetus's response to the changes in uterine activity. Therefore, assessing the FHR pattern should be the first priority after a labor progress and amniotomy.
The patient 's wife is-so anxious about the condition of her husband. The MOST appropriate INITIAL intervention for the nurse to make is to ________.
- A. describe her husband 's medical treatment since admission
- B. reassure her that the important fact is her presence
- C. explain the nature of the injury and reassure her that husband's condition is stable
- D. allow her to verbalize her feelings and concerns
Correct Answer: C
Rationale: In situations where a patient's family member is expressing anxiety about their loved one's condition, it is important for the nurse to provide clear and accurate information about the patient's status. By explaining the nature of the injury and reassuring the wife that her husband's condition is stable, the nurse can help alleviate her anxiety and address her concerns in a meaningful way. This intervention focuses on open communication and providing emotional support, which are crucial in helping the family member cope with the situation. It is essential to establish trust and create a supportive environment for the family member during this stressful time.