Nokea
After administering anesthesia to the patient, the nurse notices a sudden drop in blood pressure. What is the nurse's priority action?
- A. Administer vasopressors to increase blood pressure
- B. Assess the patient's airway, breathing, and circulation
- C. Document the blood pressure readings in the anesthesia record
- D. Notify the anesthesiologist immediately
Correct Answer: B
Rationale: The nurse's priority action after noticing a sudden drop in blood pressure after administering anesthesia is to assess the patient's airway, breathing, and circulation (ABCs). This is crucial to determine the immediate cause of the sudden drop in blood pressure and to ensure the patient's safety and stability. Assessment of the ABCs will help identify any potential airway obstruction, respiratory distress, or circulatory issues that may be contributing to the drop in blood pressure. Once the assessment is done, appropriate interventions can be initiated to stabilize the patient's condition. Administering vasopressors, documenting the blood pressure readings, and notifying the anesthesiologist are important actions but assessing the ABCs takes precedence in this situation to ensure the patient's immediate needs are addressed.
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A nurse is preparing to assist with a cardiopulmonary resuscitation (CPR) procedure for a patient in cardiac arrest. What action should the nurse prioritize during the initial assessment?
- A. Administering oxygen via nasal cannula at 2 liters per minute
- B. Checking for responsiveness and calling for help immediately
- C. Placing the patient in the recovery position to facilitate breathing
- D. Assessing the patient's airway, breathing, and circulation (ABCs)
Correct Answer: D
Rationale: The correct action to prioritize during the initial assessment when preparing to assist with a cardiopulmonary resuscitation (CPR) procedure for a patient in cardiac arrest is to assess the patient's airway, breathing, and circulation (ABCs). This involves quickly checking the patient's airway for any obstructions, assessing their breathing for signs of breathing difficulties or absence of breathing, and evaluating their circulation by checking for a pulse. This step is crucial in determining the need for immediate intervention, such as clearing the airway, providing rescue breaths, or initiating chest compressions. By prioritizing the assessment of the ABCs, the nurse can promptly identify and address life-threatening issues to improve the patient's chances of survival during a cardiac arrest situation.
A woman in active labor is receiving intravenous fentanyl for pain relief. What fetal assessment finding indicates potential neonatal opioid withdrawal syndrome (NOWS)?
- A. Hypertonicity
- B. Bradycardia
- C. Hypoglycemia
- D. Respiratory depression
Correct Answer: A
Rationale: Neonatal Opioid Withdrawal Syndrome (NOWS), previously known as Neonatal Abstinence Syndrome (NAS), can occur when a newborn is exposed to opioids in utero. Opioid exposure in utero can lead to physical dependence in the fetus, and when the drug is no longer available after birth, withdrawal symptoms can occur.
A patient with a history of coronary artery disease is prescribed aspirin for antiplatelet therapy. Which information is important for the nurse to include in patient education about aspirin therapy?
- A. "Take aspirin with a full glass of milk to minimize gastrointestinal upset."
- B. "Avoid using nonsteroidal anti-inflammatory drugs (NSAIDs) while taking aspirin."
- C. "Discontinue aspirin therapy if you develop a fever."
- D. "Take aspirin on an empty stomach for better absorption."
Correct Answer: B
Rationale: The correct information for the nurse to include in patient education about aspirin therapy is to advise the patient to avoid using nonsteroidal anti-inflammatory drugs (NSAIDs) while taking aspirin. NSAIDs can increase the risk of gastrointestinal bleeding when taken along with aspirin, which is already a blood-thinning medication due to its antiplatelet effects. Patients with coronary artery disease are typically prescribed aspirin for its antiplatelet properties to prevent blood clot formation in the arteries. Avoiding NSAIDs will help reduce the risk of gastrointestinal complications and ensure the effectiveness of aspirin therapy in preventing cardiovascular events. Taking aspirin with a full glass of milk (Option A) is not a necessary instruction for aspirin therapy. Discontinuing aspirin therapy if a patient develops a fever (Option C) is not a standard practice unless advised by a healthcare provider. Taking aspir
Lillian asks the nurse the cause of this ailment. Which of the following would the nurse explain as predisposing factors of mastitis? (Select all that apply) I. Milk stasis II. Nipple trauma III. Using alcohol in cleaning nipples IV. Baby 's sitting position
- A. II and IV
- B. I and II
- C. I and IV
- D. II and III
Correct Answer: B
Rationale: Mastitis is typically caused by bacterial infection, with predisposing factors including milk stasis (I) and nipple trauma (II). Milk stasis occurs when milk is not effectively removed from the breast, leading to a build-up that can block ducts and predispose to infection. Nipple trauma, such as cracks or damage, can provide entry points for bacteria to infect the breast tissue. Factors like using alcohol in cleaning nipples (III) and the baby's sitting position (IV) are not directly associated with the development of mastitis.
Which of the following actions is appropriate for managing a conscious patient with a suspected stroke?
- A. Administering aspirin immediately.
- B. Placing the patient in a supine position.
- C. Encouraging the patient to eat and drink.
- D. Activating emergency medical services (EMS) for rapid transport to a stroke center.
Correct Answer: D
Rationale: Activating emergency medical services (EMS) for rapid transport to a stroke center is the most appropriate action for managing a conscious patient with a suspected stroke. Time is critical in stroke care, and receiving specialized treatment at a stroke center as soon as possible can significantly improve outcomes for stroke patients. EMS providers are trained to recognize the signs of stroke and can begin essential pre-hospital care measures while en route to the hospital. Administering aspirin immediately is not recommended without medical evaluation, as certain types of strokes (such as hemorrhagic strokes) can be worsened by aspirin. Placing the patient in a supine position may not be ideal, as maintaining an elevated position can help prevent aspiration in stroke patients. Encouraging the patient to eat and drink is not appropriate, as swallowing difficulties are common in stroke patients and can lead to aspiration pneumonia.