Nokea
A woman in active labor is receiving intravenous antibiotics for group B streptococcus (GBS) prophylaxis. What maternal assessment finding indicates a potential adverse reaction to the antibiotics?
- A. Respiratory depression
- B. Urticaria and pruritus
- C. Hypertension
- D. Decreased uterine contractility
Correct Answer: B
Rationale: Urticaria (hives) and pruritus (itching) are common signs of an allergic reaction to antibiotics, including those used for GBS prophylaxis during labor. Other signs of an adverse reaction may include flushing, fever, chills, and anaphylaxis. It is important to monitor the woman closely for any signs of an allergic reaction and to intervene promptly if one occurs to ensure the safety of both the mother and the baby.
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After instructing a primiparous patient about episiotomy care, which of the following indicates successful teaching?
- A. "I will wipe the area from front to back using blotting motion "
- B. "I will put ice packs on the site 15 minutes once a day for 3 to 4 days"
- C. "Before bedtime, I will do a cold water sitz bath"
- D. "I'll use sudsy water to clean the episiotomy"
Correct Answer: A
Rationale: Wiping the episiotomy area from front to back using a blotting motion helps prevent introducing bacteria from the rectal area to the vaginal area, reducing the risk of infection. This technique also avoids causing unnecessary trauma to the healing tissues. Ensuring proper hygiene is vital to prevent complications such as infection, which is crucial for the healing process after an episiotomy.
Nurse May is alarm by the incidence of number of young adults in the community with mental problems. Which of the following should be her PRIORITY nursing initiative?
- A. Refer all tertiary hospital
- B. Request for psychiatrict drugs.
- C. Set up debriefing center
- D. Set up mental health program
Correct Answer: D
Rationale: The priority nursing initiative for Nurse May should be to set up a mental health program in the community. This proactive approach focuses on prevention, early intervention, and support for individuals experiencing mental health issues. By setting up a mental health program, Nurse May can address the root causes of mental problems in young adults in the community, provide education and awareness, offer counseling services, and promote mental well-being. This initiative can have a long-term impact on the mental health of individuals and help reduce the incidence of mental problems in the community. Setting up a mental health program is a holistic and sustainable approach to addressing mental health issues in the community.
A nurse is preparing to assist with a transurethral resection of the prostate (TURP) procedure for a patient with benign prostatic hyperplasia (BPH). What action should the nurse prioritize to prevent fluid overload during TURP?
- A. Monitoring the patient's serum electrolyte levels during the procedure
- B. Administering diuretic medications to the patient before the procedure
- C. Limiting the duration of irrigation fluid instillation during TURP
- D. Adjusting the irrigation fluid temperature to promote hemostasis
Correct Answer: C
Rationale: During a transurethral resection of the prostate (TURP), fluid irrigation is commonly used to distend the bladder and flush out tissue debris. However, it is important to prioritize preventing fluid overload in the patient. Limiting the duration of irrigation fluid instillation is a crucial action to prevent excessive fluid absorption and subsequent fluid overload. Prolonged irrigation may lead to an increased risk of fluid overload and electrolyte imbalances, which can result in serious complications such as hyponatremia and fluid volume excess. Monitoring the patient's serum electrolyte levels can be important, but limiting the duration of irrigation is a more immediate and proactive measure to prevent fluid overload. Administering diuretic medications before the procedure may not be appropriate without assessing the patient's specific fluid status and needs. Adjusting the irrigation fluid temperature, while important for hemostasis, does not directly
which is the 'MAIN' goal of ethical practice of the nursing profession including the community setting?
- A. To protect the nurse and co workers
- B. To prevent reprimand from physician
- C. For the patients Family satisfaction
- D. Centered on the welfare of clients and protect their rights
Correct Answer: D
Rationale: The main goal of ethical practice in the nursing profession, including in the community setting, is centered on the welfare of clients and protecting their rights. Nurses have a professional and ethical obligation to prioritize the well-being and best interests of their patients. This includes providing high-quality care, advocating for their patients, supporting their autonomy, and upholding their rights. Ethical nursing practice is not focused on protecting the nurse or co-workers, preventing reprimand from physicians, or solely meeting the satisfaction of patients' families. Ensuring the welfare and rights of clients is the fundamental ethical principle that guides nursing practice.
A nurse is resistant to the change and is not taking an active part in facilitating the process of change. Which is the BEST approach in dealing with the nurse?
- A. Exert coercion on the nurse
- B. Provide a positive reward system for the nurse
- C. Talk and encourage verbalizing feelings of the change
- D. Ignore the resistance of the nurse.
Correct Answer: C
Rationale: The best approach in dealing with a nurse who is resistant to change and not actively participating is to communicate and encourage verbalizing feelings about the change. By talking with the nurse and allowing them to express their concerns and feelings, you can address any underlying issues that may be causing the resistance. This approach can help build trust, improve communication, and ultimately increase the nurse's engagement in the change process. Coercion (Choice A) can create negative feelings and resistance, while ignoring the nurse's resistance (Choice D) will not resolve the issue. Providing positive rewards (Choice B) may be helpful but may not address the underlying reasons for resistance. Communication is key in addressing resistance to change and fostering a positive, open environment for all involved.