Nokea
After the procedure, the patient was ordered for Lithotripsy, under spinal anesthesia. The nurse has to call the department of ________.
- A. Internal medicine
- B. Surgery
- C. Anesthesia
- D. Imagery
Correct Answer: C
Rationale: In the provided scenario, the patient is scheduled for Lithotripsy under spinal anesthesia. This means that the nurse needs to communicate with the department of anesthesia to coordinate and prepare for the procedure. Anesthesia departments are responsible for administering various types of anesthesia, including spinal anesthesia, to ensure patients are comfortable and pain-free during medical procedures. Therefore, contacting the department of anesthesia is crucial in this situation to ensure that the necessary arrangements are in place for the patient's lithotripsy procedure.
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A woman in active labor is experiencing persistent occiput posterior position despite position changes. What nursing intervention is most appropriate to facilitate fetal rotation?
- A. Encourage the mother to remain in a side-lying position.
- B. Assist the mother into a hands-and-knees position.
- C. Administer intravenous oxytocin to augment contractions.
- D. Perform manual rotation of the fetus during vaginal examination.
Correct Answer: B
Rationale: The most appropriate nursing intervention to facilitate fetal rotation in a woman experiencing persistent occiput posterior position is to assist the mother into a hands-and-knees position. This position can help encourage the baby to rotate into the optimal occiput anterior position for delivery. By being on her hands and knees, gravity can assist in aiding the rotation of the baby. This position can also help relieve pressure on the mother's back and potentially reduce discomfort during labor. Additionally, hands-and-knees position can help open up the pelvis and create more space for the baby to turn. It is a non-invasive and generally well-tolerated intervention to promote fetal rotation in labor.
A postpartum client with a history of breast augmentation expresses concerns about breastfeeding difficulties. What nursing intervention should be prioritized to support successful breastfeeding in this situation?
- A. Providing education on techniques to promote milk production and let-down
- B. Recommending supplemental formula feedings to ensure adequate nutrition
- C. Encouraging the client to avoid breastfeeding to prevent discomfort
- D. Referring the client to a lactation consultant for specialized support
Correct Answer: D
Rationale: Referring the client to a lactation consultant for specialized support should be prioritized to support successful breastfeeding in this situation. Breast augmentation surgery may impact milk production, let-down reflex, and proper latch due to alterations in breast tissue and nerve pathways. A lactation consultant can provide individualized guidance and support to address these specific challenges. Additionally, the consultant can assist in establishing a breastfeeding plan tailored to the client's unique needs, helping to optimize the breastfeeding experience for both the mother and the baby. It is crucial to seek expert assistance in navigating any potential difficulties that may arise from breastfeeding after breast augmentation to promote successful breastfeeding outcomes.
A patient admitted to the ICU develops septic shock with refractory hypotension despite fluid resuscitation. Which intervention should the healthcare team prioritize to improve the patient's hemodynamic status?
- A. Administer vasopressor medications to increase systemic vascular resistance.
- B. Initiate continuous renal replacement therapy (CRRT) for fluid removal.
- C. Perform a bedside echocardiogram to assess cardiac function.
- D. Recommend a transfusion of packed red blood cells to optimize oxygen delivery.
Correct Answer: A
Rationale: In a patient with septic shock and refractory hypotension despite fluid resuscitation, the healthcare team should prioritize administering vasopressor medications to increase systemic vascular resistance. Vasopressors such as norepinephrine or vasopressin can be used to support blood pressure and perfusion to vital organs by constricting blood vessels and improving blood flow. By increasing systemic vascular resistance, vasopressors help to counteract the excessive vasodilation seen in septic shock and improve hemodynamic stability. It is crucial to address hypotension promptly in septic shock to prevent organ dysfunction and failure. Other interventions, such as fluid removal through continuous renal replacement therapy, assessing cardiac function with echocardiogram, or optimizing oxygen delivery through a transfusion of packed red blood cells, may be considered based on specific patient factors but do not address the primary issue of inadequate perf
A patient presents with fatigue, weakness, and jaundice. Laboratory tests reveal elevated indirect bilirubin levels, reticulocytosis, and positive Coombs test. Which of the following conditions is most likely to cause these findings?
- A. Hereditary spherocytosis
- B. Thalassemia
- C. Sickle cell disease
- D. G6PD deficiency
Correct Answer: A
Rationale: The patient's presentation of fatigue, weakness, jaundice, elevated indirect bilirubin levels, reticulocytosis, and positive Coombs test is consistent with hemolytic anemia. Among the options provided, hereditary spherocytosis is the most likely condition to cause these findings.
Nurse Edna admits a patient from the ER to the medical unit. The patient is very restless with IV lines and a urinary catheter. She was put to bed and the nurse applied a body restraint without the doctor's order. Nurse Edna's action can be liable for _____.
- A. invasion of privacy
- B. assault
- C. battery
- D. neglect
Correct Answer: C
Rationale: Battery occurs when there is an intentional harmful or offensive contact with a person without their consent. In this scenario, Nurse Edna applied a body restraint to the patient without the doctor's order, which constitutes unauthorized physical contact. The patient did not give consent for the restraint, and Nurse Edna's action could be considered battery. It is important for healthcare providers to obtain proper authorization before using any form of physical restraint on a patient to avoid legal implications such as battery.