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Before transferring the patient to the operating room (OR), the nurse notices a discrepancy between the surgical consent form and the planned procedure. What should the nurse do?
- A. Proceed with the planned procedure
- B. Inform the patient about the discrepancy
- C. Consult the surgeon for clarification
- D. Document the discrepancy in the patient's chart
Correct Answer: C
Rationale: When a nurse notices a discrepancy between the surgical consent form and the planned procedure, it is essential to consult the surgeon for clarification. The surgeon is the primary decision-maker regarding the surgical procedure and can provide insight into why the discrepancy exists and how to proceed. It is crucial to ensure that everyone is on the same page before moving forward with the surgery to prevent errors, ensure patient safety, and maintain legal and ethical standards. Consulting the surgeon allows for the issue to be addressed promptly and for the appropriate steps to be taken to resolve the discrepancy before proceeding with the surgery.
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A postpartum client who experienced a prolonged labor and instrumental delivery expresses concerns about breastfeeding difficulties. What nursing intervention should be prioritized to support successful breastfeeding in this situation?
- A. Providing education on techniques to facilitate milk let-down reflex
- B. Recommending supplemental formula feedings to ensure adequate nutrition
- C. Encouraging the client to consider exclusive formula feeding instead of breastfeeding
- D. Referring the client to a lactation consultant for specialized support
Correct Answer: D
Rationale: In the situation described, where the client experienced a prolonged labor and instrumental delivery, there may be physical and emotional factors impacting breastfeeding success. A lactation consultant is a specialized healthcare provider who can assess the client's breastfeeding difficulties, offer individualized support, and provide guidance on techniques to overcome challenges such as latch issues, positioning problems, and milk supply concerns. Referring the client to a lactation consultant will help ensure that she receives expert assistance tailored to her specific needs, thereby increasing the likelihood of successful breastfeeding. This proactive approach focuses on addressing the root causes of breastfeeding difficulties and supporting the client in achieving her breastfeeding goals.
A patient with a severe bacterial infection has elevated levels of C-reactive protein (CRP) in their blood. Which of the following functions does CRP primarily serve during the acute phase response?
- A. Opsonization of pathogens
- B. Activation of complement system
- C. Phagocytosis of pathogens
- D. Neutralization of toxins
Correct Answer: B
Rationale: During the acute phase response, C-reactive protein (CRP) primarily serves to activate the complement system. CRP binds to phosphocholine on the surface of pathogens, allowing for the activation of the classical pathway of the complement system. This leads to the recruitment of immune cells, opsonization of pathogens, and enhancement of phagocytosis. The activation of the complement system by CRP plays a crucial role in the host defense against infections, aiding in the elimination of pathogens and the resolution of inflammation.
A patient with a history of chronic kidney disease is prescribed phosphate binders. Which instruction should the nurse include in patient education about phosphate binder therapy?
- A. "Take phosphate binders with meals."
- B. "Avoid taking phosphate binders with calcium supplements."
- C. "Increase your intake of foods high in phosphorus."
- D. "Take phosphate binders on an empty stomach."
Correct Answer: A
Rationale: The correct instruction that the nurse should include in patient education about phosphate binder therapy is to "Take phosphate binders with meals." Phosphate binders are medications given to patients with chronic kidney disease to help control high phosphate levels in the blood. Taking phosphate binders with meals allows them to bind to the phosphorus present in the food, reducing its absorption in the body. This helps to lower blood phosphate levels effectively. Instructing the patient to take phosphate binders with meals ensures optimal binding of phosphorus from the diet, which is crucial for managing phosphate levels in patients with chronic kidney disease.
The FIRST PRIORITY nursing intervention during the immediate postpartum period is focused on
- A. Monitoring urinary output
- B. Taking the vital signs every 4 hours
- C. Observing postpartum hemorrhage
- D. Checking level of responsiveness
Correct Answer: C
Rationale: Postpartum hemorrhage is a serious complication that can occur within the first 24 hours after childbirth. It is the leading cause of maternal mortality worldwide. Therefore, during the immediate postpartum period, the first priority nursing intervention should be focused on observing for signs and symptoms of postpartum hemorrhage, such as excessive bleeding, abnormal vital signs, and changes in uterine tone. Early detection and prompt intervention can prevent severe complications and save the mother's life. Monitoring urinary output, taking vital signs, and checking level of responsiveness are important aspects of postpartum care but observing for postpartum hemorrhage takes precedence due to its critical nature.
A patient receiving palliative care for end-stage renal disease expresses distress over changes in body image due to edema and weight gain. What intervention should the palliative nurse prioritize to address the patient's concerns?
- A. Encourage the patient to focus on accepting their body changes as part of the illness.
- B. Provide education on dietary modifications to manage fluid retention and edema.
- C. Offer emotional support and validate the patient's feelings about body image changes.
- D. Prescribe diuretic medications to reduce fluid retention and alleviate edema.
Correct Answer: C
Rationale: The most appropriate intervention for the palliative nurse to prioritize in this situation is to offer emotional support and validate the patient's feelings about body image changes. End-stage renal disease can lead to significant physical changes such as edema and weight gain, which can impact a patient's body image and self-esteem. By providing emotional support and validating the patient's feelings, the nurse can help address the patient's distress and concerns, improving their overall psychological well-being. While providing education on dietary modifications (choice B) and prescribing diuretic medications (choice D) may be important aspects of managing fluid retention and edema, addressing the patient's emotional distress and body image concerns should be the initial priority in a palliative care setting. Encouraging the patient to accept their body changes (choice A) may overlook the emotional impact these changes have on the patient, making choice C the most appropriate intervention.