Nokea
A woman in active labor is experiencing intense pain and requests non-pharmacological pain relief measures. What intervention should the nurse prioritize?
- A. Providing continuous labor support
- B. Administering intravenous opioids
- C. Performing epidural analgesia
- D. Initiating nitrous oxide inhalation
Correct Answer: A
Rationale: When a woman in active labor is experiencing intense pain and requests non-pharmacological pain relief measures, the nurse should prioritize providing continuous labor support. Continuous labor support, also known as a doula or labor companion, has been shown to be effective in reducing the perception of pain and improving labor outcomes. The presence of a supportive person can provide physical, emotional, and informational support, helping the woman cope with the pain and navigate through the labor process. This intervention can enhance the woman's overall experience of labor and improve maternal and neonatal outcomes without the need for pharmacological interventions. Administering opioids, performing epidural analgesia, or initiating nitrous oxide inhalation are pharmacological pain relief measures and may not align with the woman's preference for non-pharmacological options.
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Which is the APPROPRIATE way to correct an error in the Nurses Notes?
- A. Take the whole page out and replace with a fresh one
- B. Draw a single 1ine across the error and initial it
- C. Use the sticky side of the plastic tape to erase the error
- D. Use a rubber eraser to erase an error.
Correct Answer: B
Rationale: The appropriate way to correct an error in the Nurses Notes is to draw a single line across the error and initial it. This method is recommended because it indicates that there was an error made, while still preserving the original information for audit and legal purposes. It shows transparency and accountability in documentation, as the original information remains visible. Taking the whole page out and replacing it with a fresh one can lead to discrepancies and potential legal issues if there are inconsistencies in the documentation. Using methods like using the sticky side of the plastic tape or a rubber eraser can make the documentation look unprofessional and raises questions about the accuracy and integrity of the notes.
In order for Nurse Cris to facilitate the recognition of the community the existence of their health problems, which nursing action would yield BETTER results?
- A. Asks the barangay head to make the report
- B. Set the ground rule that presence of problem is valid
- C. Allows people's participation to confirm the health problems.
- D. Acts as an expert to communicate to residents.
Correct Answer: C
Rationale: Allowing people's participation to confirm the health problems would yield better results in facilitating the recognition of the community's health issues. By involving the community members themselves in the process of identifying and acknowledging their health problems, there is a higher likelihood of garnering accurate and relevant information. This participatory approach fosters a sense of ownership and empowerment among the community members, making them more likely to actively engage in addressing the identified health concerns. Additionally, community participation can help build trust between the nurse and the residents, leading to more effective communication and collaboration in improving overall health outcomes.
A patient presents with recurrent episodes of epistaxis, particularly after blowing the nose or during dry weather. Anterior rhinoscopy reveals a friable, vascular lesion in Little's area. Which of the following interventions is most appropriate for managing this condition?
- A. Nasal packing with anterior nasal tampons
- B. Application of silver nitrate cautery
- C. Endoscopic cauterization of the sphenopalatine artery
- D. Surgical excision of the nasal polyp
Correct Answer: B
Rationale: The clinical scenario described is consistent with a diagnosis of anterior epistaxis due to a prominent vascular lesion located in Little's area, which is an important site for nosebleeds. Silver nitrate cautery is the most appropriate intervention for managing this condition. Silver nitrate cautery is a commonly used method to chemically cauterize and eliminate the friable blood vessels responsible for recurrent epistaxis. It is a cost-effective and minimally invasive technique that can be easily performed in an outpatient setting. Nasal packing with anterior nasal tampons might be considered in cases of severe or refractory epistaxis, but in this scenario, where the source of bleeding is localized and identifiable, silver nitrate cautery is the treatment of choice. Endoscopic cauterization of the sphenopalatine artery and surgical excision of a nasal polyp are unnecessary and overly invasive for the described scenario.
You accidentally touch Claudia's eyelid during eye drop instillation causing her to blink. What should have you done to prevent this from occurring?
- A. Touch the inner side of the medicine cap
- B. Tilt back Claudia's head slightly
- C. Hold the dropper close to the eye but do not allow the medication to fall into the cornea
- D. Have Claudia look up and focus on something
Correct Answer: B
Rationale: Tilt back Claudia's head slightly would have been the correct action to prevent her from blinking during eye drop instillation. By tilting her head back, you create a more stable position for instilling the eye drops, reducing the likelihood of accidental contact with her eyelid. Additionally, tilting the head back slightly helps in making it easier for the drops to enter the eye and stay within the conjunctival sac, improving the efficacy of the medication.
A patient in the ICU develops catheter-related bloodstream infection (CRBSI) associated with a central venous catheter. What intervention should the healthcare team prioritize to manage the patient's infection?
- A. Remove the central venous catheter to eliminate the source of infection.
- B. Administer broad-spectrum antibiotics targeting common pathogens.
- C. Perform blood cultures to identify the causative organism.
- D. Implement sterile dressing changes and catheter care protocols.
Correct Answer: A
Rationale: The primary intervention that should be prioritized for managing a catheter-related bloodstream infection (CRBSI) associated with a central venous catheter is to remove the central venous catheter. CRBSI is a serious complication that can lead to severe infections and sepsis. The removal of the catheter is crucial to eliminate the source of the infection and prevent further dissemination of the pathogens into the bloodstream. Once the catheter is removed, the healthcare team can consider other interventions such as administering targeted antibiotics based on culture results, performing blood cultures to identify the causative organism, and implementing sterile dressing changes and catheter care protocols. However, immediate removal of the catheter takes precedence in managing CRBSI to prevent worsening of the infection and improve patient outcomes.