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A postpartum client presents with sudden onset of shortness of breath, chest pain, and cyanosis. Which nursing action is most appropriate?
- A. Placing the client in a semi-Fowler's position
- B. Administering supplemental oxygen therapy
- C. Notifying the healthcare provider immediately
- D. Assisting with chest physiotherapy to improve ventilation
Correct Answer: C
Rationale: The sudden onset of shortness of breath, chest pain, and cyanosis in a postpartum client could be indicative of a pulmonary embolism, a potentially life-threatening condition. Therefore, it is crucial to notify the healthcare provider immediately for further assessment and management. Prompt intervention is essential in this situation to prevent any potential complications and ensure the client receives appropriate care as soon as possible. Placing the client in a semi-Fowler's position or administering supplemental oxygen therapy may provide temporary relief, but the priority is to seek immediate medical attention. Consulting with the healthcare provider ensures that the client receives the necessary interventions promptly.
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A patient admitted to the ICU develops severe sepsis with refractory hypotension despite adequate fluid resuscitation. What intervention should the healthcare team prioritize to manage the patient's septic shock?
- A. Administer vasopressor medications to restore vascular tone.
- B. Perform blood cultures to identify the causative pathogen.
- C. Initiate broad-spectrum antibiotics targeting likely pathogens.
- D. Recommend prophylactic anticoagulation to prevent thrombosis.
Correct Answer: A
Rationale: In the scenario described, the patient is experiencing refractory hypotension despite adequate fluid resuscitation, indicating the presence of septic shock. In septic shock, systemic vasodilation and vascular hyporesponsiveness contribute to hypotension. Therefore, the primary management approach is to restore vascular tone and blood pressure to maintain organ perfusion. Administering vasopressor medications (Choice A) is the crucial intervention to achieve this goal. Vasopressors, such as norepinephrine or vasopressin, constrict blood vessels and increase blood pressure, helping to stabilize the patient in septic shock. While options B and C (performing blood cultures and initiating broad-spectrum antibiotics) are important for identifying the causative pathogen and treating the infection, they are secondary to the immediate need for hemodynamic support in septic shock. Prophylactic anticoagulation (Choice D) is not the primary intervention for
A patient presents with a small, painless, well-defined nodule on the lateral aspect of the neck, just above the clavicle. Fine-needle aspiration cytology reveals clusters of polygonal cells with abundant granular cytoplasm. Which of the following conditions is most likely responsible for this presentation?
- A. Thyroglossal duct cyst
- B. Branchial cleft cyst
- C. Lymphadenopathy
- D. Parathyroid adenoma
Correct Answer: D
Rationale: The presentation of a small, painless, well-defined nodule on the lateral aspect of the neck, above the clavicle, along with the cytology showing clusters of polygonal cells with abundant granular cytoplasm is most indicative of a parathyroid adenoma. Parathyroid adenomas are benign tumors derived from the parathyroid gland that can produce excess parathyroid hormone (PTH), leading to hyperparathyroidism. The characteristic histology of parathyroid adenomas includes chief cells with abundant granular cytoplasm.
A patient is prescribed a loop diuretic for the management of heart failure. Which electrolyte imbalance is most commonly associated with loop diuretic therapy?
- A. Hypercalcemia
- B. Hypokalemia
- C. Hypernatremia
- D. Hypomagnesemia
Correct Answer: B
Rationale: Loop diuretics such as furosemide are commonly prescribed for the management of heart failure to reduce fluid overload and lower blood pressure by increasing the excretion of sodium and water. These medications promote the loss of potassium through increased urinary output. Hypokalemia, or low potassium levels in the blood, is the most common electrolyte imbalance associated with loop diuretic therapy. Potassium is an essential electrolyte for proper functioning of the heart, muscles, and nerves. Low potassium levels can lead to symptoms such as muscle weakness, cramps, and potentially life-threatening cardiac arrhythmias. Patients on loop diuretics are often monitored for potassium levels, and sometimes potassium supplements may be prescribed to prevent or correct hypokalemia.
What is the appropriate ratio of chest compressions to rescue breaths for adult CPR?
- A. 15 compressions: 2 breaths
- B. 30 compressions: 2 breaths
- C. 30 compressions: 1 breath
- D. 15 compressions: 1 breath
Correct Answer: C
Rationale: The appropriate ratio of chest compressions to rescue breaths for adult CPR is 30 compressions to 2 breaths. This means that after every 30 chest compressions, two rescue breaths should be given. This ratio helps in maintaining oxygen circulation in the body while also ensuring that the heart is being effectively pumped to circulate blood. The emphasis on chest compressions is critical in maintaining blood flow to vital organs during cardiac arrest, while the rescue breaths help in providing oxygen to the patient's lungs. This ratio is recommended by organizations like the American Heart Association for performing high-quality adult CPR.
Nurse Gay is assigned in the Medical Unit. She is guided that in documentation, she should use abbreviation that is ______.
- A. used automatically to save precious time.
- B. reduced to the minimum in all units.
- C. approved standard list by the hospital.
- D. not used at all because it can be misinterpreted.
Correct Answer: C
Rationale: Nurse Gay should use abbreviations that are part of an approved standard list by the hospital. Using standardized abbreviations ensures clarity, accuracy, and consistency in documentation. It helps in preventing misinterpretation, errors, and ambiguity in patient records. By following an approved list of abbreviations, healthcare professionals can communicate effectively and efficiently while maintaining patient safety and quality of care.