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Considering the pain assessment scale (1, is the least pain and 5 is the most painful) Mrs. P described her pain in the scale of 5, you expect that the doctor will order which of the following pain medication?
- A. Meperidine HCl. (Demerol)
- B. Morphine Sulphate
- C. Fentanyl (Duragesic)
- D. Acetaminophen (Tylenol)
Correct Answer: B
Rationale: When a patient describes their pain as a 5 on the pain assessment scale, it indicates severe pain and the need for a strong pain medication. Morphine Sulphate is a potent opioid analgesic that is commonly used to manage severe pain, such as in cases where the pain is rated as 5. Meperidine HCl (Demerol) is another opioid analgesic, but it is not as commonly used due to its side effect profile and potential for toxicity. Fentanyl (Duragesic) is also a potent opioid analgesic that can be used for severe pain, but morphine is often preferred in this situation. Acetaminophen (Tylenol) is a milder pain reliever and is not typically sufficient for pain described at a level of 5 on the pain scale.
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Nurse Cris received information from some community residents who suspect that a neighbor ls abusing his young child. Which should be the PRIORITY nursing action ?
- A. Report the police authorities.
- B. Notify the social worker.
- C. Ignore the information
- D. Validate the information
Correct Answer: A
Rationale: The PRIORITY nursing action when receiving information about suspected child abuse is to report to the police authorities. Child abuse is a serious issue that requires immediate intervention to ensure the safety and well-being of the child. The police are trained to investigate these types of situations and can take the necessary steps to protect the child from harm. It is essential to act swiftly and report any suspicions of child abuse to the proper authorities to prevent further harm and ensure the child's safety.
With diagnosis of hemorrhagic stroke, the nurse teaches the caregiver that with position of the bed should be in what position?
- A. High-Fowler's
- B. Prone
- C. Fowler
- D. Flat
Correct Answer: A
Rationale: For a patient diagnosed with a hemorrhagic stroke, the caregiver should ensure that the bed is positioned in a High-Fowler's position. This position involves elevating the head of the bed between 60 to 90 degrees. Elevating the head of the bed helps to reduce intracranial pressure and promote optimal cerebral perfusion. It also assists in maintaining proper ventilation and oxygenation, which are essential for the patient's recovery. It is important to avoid positioning the patient flat or in a prone position as these may exacerbate the condition and lead to further complications.
The nurse educator Adalynn reviewed the risk factors for postpartum hemorrhage for the mothers. Which of the following factors IS NOT included ____?
- A. ruptured uterus
- B. uterine atony
- C. overdistended uterus
- D. retroversion of the uterus
Correct Answer: D
Rationale: Postpartum hemorrhage (PPH) is a significant complication after childbirth. The risk factors for PPH that are typically included in the list are uterine atony, overdistended uterus (e.g., multiple gestation or polyhydramnios), and ruptured uterus. Retroversion of the uterus is not a known risk factor for PPH. Retroversion refers to the position of the uterus, where it is tilted back towards the rectum. While retroverted uterus can sometimes lead to other issues or complications during pregnancy, it is not directly associated with an increased risk of postpartum hemorrhage.
Which assessment findings is INDICATIVE of the diagnosis of hypertension?
- A. Family members with high blood pressure
- B. Elevation of blood cholesterol level
- C. Stressful work environment
- D. Consistent evaluation of blood pressure
Correct Answer: D
Rationale: The assessment finding that is indicative of the diagnosis of hypertension is consistent evaluation of blood pressure. Hypertension is diagnosed based on repeated measurements of elevated blood pressure. Consistently high blood pressure readings, usually defined as systolic blood pressure consistently at or above 140 mmHg and diastolic blood pressure consistently at or above 90 mmHg, are a key factor in diagnosing hypertension. Family history of high blood pressure (Choice A), elevation of blood cholesterol level (Choice B), and a stressful work environment (Choice C) may be risk factors for hypertension but are not diagnostic criteria. In order to diagnose hypertension, healthcare providers rely on consistent measurement and evaluation of blood pressure over time.
A postpartum client who delivered twins expresses concerns about breastfeeding both infants simultaneously. What nursing intervention should be prioritized to address the client's concerns?
- A. Demonstrating tandem breastfeeding positions and techniques
- B. Recommending the use of nipple shields to facilitate latch for both infants
- C. Encouraging the client to alternate breastfeeding sessions between the infants
- D. Referring the client to a lactation consultant for assistance
Correct Answer: A
Rationale: Demonstrating tandem breastfeeding positions and techniques should be prioritized as the nursing intervention to address the client's concerns about breastfeeding both infants simultaneously. Tandem breastfeeding involves nursing twins at the same time and can help enhance milk production, promote bonding with both infants, and save time for the mother. By showing the client the proper positions and techniques for tandem breastfeeding, the nurse can empower the client with the knowledge and skills needed to successfully breastfeed both infants together. This intervention can ultimately support the client in feeling more confident and competent in managing the challenges of breastfeeding twins.