Nokea
A postpartum client presents with severe abdominal pain, nausea, and vomiting. Which nursing action is most appropriate?
- A. Administering antiemetic medication as ordered
- B. Encouraging the client to drink clear fluids
- C. Assessing for signs of peritonitis or surgical abdomen
- D. Providing a heating pad to alleviate abdominal discomfort
Correct Answer: C
Rationale: In a postpartum client who presents with severe abdominal pain, nausea, and vomiting, it is crucial to assess for signs of peritonitis or surgical abdomen. These signs may include rebound tenderness, guarding, rigidity, and fever. Peritonitis is a serious condition that may require immediate surgical intervention. Administering antiemetic medication, encouraging clear fluids, or providing a heating pad may not address the underlying cause of the symptoms and delay appropriate treatment. Assessing for signs of peritonitis or surgical abdomen is crucial for prompt identification and management of the client's condition.
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A patient with suspected community-acquired pneumonia (CAP) is empirically started on antibiotic therapy pending culture results. Which of the following antibiotic regimens provides appropriate coverage for typical bacterial pathogens commonly implicated in CAP?
- A. Ceftriaxone and azithromycin
- B. Vancomycin and piperacillin/tazobactam
- C. Ampicillin-sulbactam and levofloxacin
- D. Clindamycin and cefepime
Correct Answer: A
Rationale: The correct answer is A: Ceftriaxone and azithromycin. Ceftriaxone covers Streptococcus pneumoniae, the most common pathogen in CAP, while azithromycin covers atypical pathogens like Mycoplasma pneumoniae. Vancomycin and piperacillin/tazobactam (choice B) are not first-line treatments for CAP. Ampicillin-sulbactam and levofloxacin (choice C) cover some pathogens but not as comprehensively as ceftriaxone and azithromycin. Clindamycin and cefepime (choice D) do not provide adequate coverage for typical CAP pathogens.
Which of the following actions should be taken first when encountering a person experiencing an allergic reaction with signs of respiratory distress?
- A. Administer an epinephrine auto-injector.
- B. Position the person comfortably.
- C. Monitor vital signs.
- D. Assess the severity of the reaction.
Correct Answer: D
Rationale: The correct answer is D: Assess the severity of the reaction. This should be the first action taken because it helps determine the urgency of the situation and guides subsequent steps. Assessing the severity allows for appropriate intervention - from calling emergency services if the reaction is severe, to administering medication if necessary.
A: Administering an epinephrine auto-injector should only be done if the severity of the reaction warrants it, as it is a potent medication that can have serious side effects if used inappropriately.
B: Positioning the person comfortably is important, but assessing the severity of the reaction takes precedence to ensure prompt and appropriate care.
C: Monitoring vital signs is important, but assessing the severity of the reaction is crucial in determining the immediate course of action.
You should check the patient for suspect disturbed thought processes related to depressed metabolism and altered cardiovascular and respiratory status. What is the rationale for orienting the patient to time, place, date, and events?
- A. Shows improved cognitive functioning
- B. Provides reality orientation to patient
- C. Permits evaluation of effectiveness of treatment
- D. Let the patient identify the time, place, date, and events correctly
Correct Answer: B
Rationale: The correct answer is B: Provides reality orientation to patient. Orienting the patient to time, place, date, and events helps them stay connected to reality and improves their awareness of their surroundings. This is crucial in assessing their cognitive functioning and ensuring they are grounded in the present moment. By providing reality orientation, healthcare providers can better understand the patient's current mental state and address any potential confusion or disorientation. This approach aids in establishing a therapeutic environment and enhances the patient's overall well-being. Choices A, C, and D do not capture the essence of reality orientation and its significance in maintaining the patient's mental clarity and connection to the present moment.
A woman in active labor demonstrates signs of uterine inertia, with weak and irregular contractions contributing to slow cervical dilation. What nursing intervention should be implemented to address this abnormal labor pattern?
- A. Administering intravenous oxytocin to augment contractions
- B. Preparing for immediate cesarean section
- C. Facilitating maternal rest and hydration
- D. Performing an emergency manual rotation of the fetus
Correct Answer: A
Rationale: In cases of uterine inertia, where weak and irregular contractions are causing slow cervical dilation during labor, administering intravenous oxytocin can help augment contractions and stimulate more effective progress. Oxytocin is a hormone that naturally stimulates uterine contractions and is commonly used in clinical settings to induce or enhance labor. By increasing the strength and frequency of contractions, oxytocin can help address uterine inertia and promote efficient cervical dilation to facilitate the progress of labor. It is important to monitor the response to oxytocin carefully to avoid complications such as hyperstimulation of the uterus, which can lead to fetal distress.
A patient with a history of congestive heart failure is prescribed furosemide. Which electrolyte imbalance is the patient at risk for developing with furosemide therapy?
- A. Hyperkalemia
- B. Hypokalemia
- C. Hyponatremia
- D. Hypernatremia nd potassium. Therefore, patients taking furosemide are at risk for developing hypokalemia due to increased potassium excretion.
Correct Answer: B
Rationale: Step 1: Furosemide is a loop diuretic that works in the ascending loop of Henle to inhibit sodium and chloride reabsorption.
Step 2: Inhibition of sodium reabsorption leads to increased water and electrolyte excretion, including potassium.
Step 3: Increased potassium excretion can lead to hypokalemia, which is a common side effect of loop diuretics like furosemide.
Step 4: Hypokalemia can be dangerous, especially in patients with congestive heart failure, as it can worsen cardiac function and lead to arrhythmias.
Step 5: Therefore, patients with a history of congestive heart failure prescribed furosemide are at risk for developing hypokalemia due to increased potassium excretion.