Nokea
After the surgical procedure, the nurse assists with applying the surgical dressing. What is the nurse's priority action?
- A. Documenting the dressing change in the patient's chart
- B. Assessing the surgical incision for signs of complications
- C. Providing instructions to the patient about wound care
- D. Ensuring that the dressing is applied securely and correctly
Correct Answer: B
Rationale: The nurse's priority action after applying the surgical dressing is to assess the surgical incision for signs of complications. This includes checking for any signs of infection, excessive bleeding, or other complications related to the surgical site. Early detection of such complications is crucial for ensuring proper healing and preventing serious complications. Once the assessment is done and any issues are addressed, the nurse can proceed with documenting the dressing change, providing instructions to the patient about wound care, and ensuring that the dressing is securely and correctly applied.
You may also like to solve these questions
A woman in active labor experiences persistent fetal malposition, with the fetus in a transverse lie presentation. What nursing intervention should be prioritized to address this abnormal labor presentation?
- A. Facilitating external cephalic version (ECV)
- B. Assisting the mother into a hands-and-knees position
- C. Preparing for immediate instrumental delivery
- D. Initiating continuous electronic fetal monitoring
Correct Answer: B
Rationale: When a woman in active labor experiences persistent fetal malposition, such as a transverse lie presentation, assisting the mother into a hands-and-knees position is a nursing intervention to prioritize. This position can help encourage the fetus to rotate into a more favorable position for delivery, such as a head-down position. By placing the mother in a hands-and-knees position, gravity can assist in shifting the fetus to the correct position. This intervention is non-invasive and can be effective in promoting the progress of labor and avoiding the need for more invasive interventions like instrumental delivery or cesarean section. However, if the fetus does not rotate or if there are signs of fetal distress, further interventions may be necessary.
She plans to interview the Psyche Nurse Manager about the patient safety practices of the nurses. What type of sampling includes those who happen to be in the conference room where the activity is scheduled?
- A. Random
- B. convenience
- C. Purposive
- D. Quota
Correct Answer: B
Rationale: Convenience sampling involves selecting participants who are readily available or easy to access. In this scenario, choosing to interview nurses who happen to be in the conference room where the activity is scheduled falls under convenience sampling as they are easily accessible at that moment. While convenience sampling may be convenient, it may introduce bias and may not represent the entire population accurately.
During a shift handover, the nurse receives information about a patient's condition from the outgoing nurse. What action by the nurse demonstrates effective communication during the handover process?
- A. Interrupting the outgoing nurse to ask questions
- B. Writing down the information without asking for clarification
- C. Summarizing key points and asking clarifying questions as needed
- D. Disregarding the information and relying on personal assessment later
Correct Answer: C
Rationale: Option C, summarizing key points and asking clarifying questions as needed, demonstrates effective communication during the handover process. This action ensures that the nurse fully understands the information being provided and helps to prevent misunderstandings or missing critical details. By summarizing key points, the nurse confirms their understanding and can ask for clarification on any areas that are unclear. Effective communication during handovers is essential for maintaining patient safety and continuity of care.
A postpartum client is breastfeeding and expresses discomfort during feedings due to sore nipples. What nursing intervention should be prioritized to alleviate nipple soreness?
- A. Educating the client on proper latch technique
- B. Recommending the use of nipple shields during feedings
- C. Applying lanolin cream to the nipples after each feeding
- D. Encouraging the use of breast pumps instead of direct breastfeeding
Correct Answer: A
Rationale: Proper latch technique is the most important nursing intervention to alleviate nipple soreness in a breastfeeding client. When a baby latches on correctly, it helps prevent nipple trauma and soreness. Educating the client on how to achieve a proper latch, such as ensuring the baby's mouth covers both the nipple and areola, can significantly reduce discomfort during feedings. Improving the latch can also enhance milk transfer, leading to better breastfeeding outcomes for both the mother and baby. While lanolin cream (choice C) can provide some relief for sore nipples, addressing the root cause by correcting the latch is crucial for long-term comfort and successful breastfeeding. Using nipple shields (choice B) or encouraging the use of breast pumps (choice D) should not be the first line of intervention when addressing sore nipples, as they do not address the underlying issue of latch technique.
A postpartum client presents with persistent, severe abdominal pain, distention, and absent bowel sounds. Which nursing action is most appropriate?
- A. Encouraging the client to ambulate to promote bowel function
- B. Providing a heating pad to alleviate abdominal discomfort
- C. Notifying the healthcare provider immediately
- D. Administering a laxative to promote bowel evacuation
Correct Answer: C
Rationale: The most appropriate nursing action in this situation is to notify the healthcare provider immediately. The symptoms the postpartum client is experiencing - persistent, severe abdominal pain, distention, and absent bowel sounds - are concerning and could indicate a serious underlying issue such as bowel obstruction or other complications. Prompt communication with the healthcare provider is crucial to ensure the client receives the necessary assessment, intervention, and treatment. Encouraging ambulation, providing a heating pad, or administering a laxative are not appropriate actions in this case without first consulting with the healthcare provider due to the severity and potential complexity of the client's symptoms.