Nokea
An infant is born precipitously outside the labor room. What should the nurse do first?
- A. Tie and cut the umbilical cord
- B. Establish an airway for the newborn
- C. Ascertain the condition of the uterine fundus
- D. Arrange transport for the mother and infant to the birthing unit
Correct Answer: B
Rationale: Precipitous birth outside controlled settings demands urgent action. Tying/cutting the cord (choice A) is secondary; delay poses no immediate risk unless bleeding occurs. Establishing an airway (choice B) is first, as newborns must breathe independently clearing mucus or stimulating crying ensures oxygenation, critical within the golden minute. Checking the fundus (choice C) assesses maternal bleeding, a later priority. Transport (choice D) follows stabilization. B is correct, per neonatal resuscitation guidelines. Nurses clear airways, warm the infant, and then address cord and maternal needs, ensuring survival.
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The nurse is caring for a client with a suspected myocardial infarction. Which laboratory value is most specific for confirming the diagnosis?
- A. Troponin I
- B. Creatine kinase (CK)
- C. Myoglobin
- D. Lactic dehydrogenase (LDH)
Correct Answer: A
Rationale: Troponin I is the most specific marker for myocardial infarction, rising within hours and staying elevated for days CK and myoglobin are less specific, LDH is outdated. Nurses monitor this, correlating with ECG and symptoms, aiding rapid diagnosis and treatment.
A woman in labor is receiving an antibiotic. She suddenly complains of trouble breathing, weakness and nausea. The nurse should recognize that these signs are usually indicative of impending:
- A. Pulmonary egophony
- B. Amniotic fluid embolism
- C. Anaphylaxis
- D. Bronchospasm
Correct Answer: C
Rationale: Sudden breathing difficulty, weakness, and nausea during antibiotic administration suggest a severe allergic reaction, known as anaphylaxis. This life-threatening condition involves systemic histamine release, causing airway constriction, hypotension, and gastrointestinal distress. Pulmonary egophony relates to lung sound changes, not systemic symptoms. Amniotic fluid embolism presents with cardiovascular collapse and bleeding, not primarily nausea. Bronchospasm is airway narrowing but lacks the broader symptoms here. Immediate recognition of anaphylaxis prompts epinephrine administration and airway support, critical for maternal and fetal survival in labor.
Which standards are monitored by the Quality and Safety Education for Nurses (QSEN)?
- A. Evidence-based practice
- B. Client-centered care
- C. Informatics
- D. Nursing certification
Correct Answer: A
Rationale: The Quality and Safety Education for Nurses (QSEN) initiative defines key competencies to ensure nurses deliver safe, high-quality care, addressing modern healthcare demands. Evidence-based practice integrates the best research with clinical expertise, guiding decisions for effective outcomes. Client-centered care prioritizes individual needs and preferences, balancing advocacy with safety. Informatics leverages technology for accurate documentation and care evaluation, enhancing efficiency. Quality improvement drives ongoing assessment and refinement of practices, while teamwork and collaboration ensure coordinated care delivery. Safety minimizes risks, a core QSEN focus. Nursing certification, though valuable, isn't a QSEN competency, as it's an individual credential, not a universal standard. These standards collectively equip nurses to improve care quality and safety across settings, reflecting a comprehensive approach to professional development and patient well-being.
Which of the following statement is TRUE about tertiary care?
- A. Provided by general practitioners
- B. Focuses on health promotion
- C. Highly specialized care
- D. All of the above
Correct Answer: C
Rationale: Tertiary care is highly specialized (C), per system e.g., surgery, rehab. Not by GPs (A), not promotion (B), not all (D) advanced focus. C truly defines tertiary's complexity, making it correct.
The nurse touched Mr. Gary without consent during care. This is an example of?
- A. Battery
- B. Assault
- C. Justice
- D. Nonmaleficence
Correct Answer: A
Rationale: Touching without consent is battery (A) unconsented contact, per law. Assault (B) threat, justice (C) fairness, nonmaleficence (D) harm avoidance not contact-specific. A fits the nurse's breach of Mr. Gary's autonomy, making it correct.