Nokea
During surgery, the nurse observes an unusual odor emanating from the surgical site. What should the nurse do?
- A. Document the observation in the patient's chart
- B. Ignore the odor and continue with the procedure
- C. Inform the surgeon immediately and assess for signs of infection
- D. Request additional suctioning to remove the odor
Correct Answer: C
Rationale: If the nurse observes an unusual odor emanating from the surgical site during surgery, it is important to inform the surgeon immediately and assess for signs of infection. Changes in odor can sometimes be an early sign of infection, which requires prompt attention and intervention. By communicating with the surgeon and conducting a thorough assessment, the nurse can help ensure the timely detection and management of any potential complications, such as infection, that may be affecting the patient's surgical outcome. Prompt action in response to unusual observations is crucial to maintaining patient safety and well-being during surgical procedures.
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Which of the following structures is responsible for propelling food from the oral cavity to the stomach through coordinated muscular contractions?
- A. Tongue
- B. Pharynx
- C. Esophagus
- D. Epiglottis
Correct Answer: C
Rationale: The esophagus is responsible for propelling food from the oral cavity to the stomach through a series of coordinated muscular contractions. These contractions are known as peristalsis. The esophagus is a muscular tube connecting the throat (pharynx) to the stomach and plays a crucial role in moving food bolus from the mouth to the stomach for digestion. The tongue helps in the chewing and swallowing of food, the pharynx is involved in the passage of food and air, and the epiglottis helps prevent food from entering the airways during swallowing. However, it is the esophagus that actively moves the food to the stomach.
A woman in active labor has a prolonged second stage with inadequate expulsive efforts. What nursing intervention is appropriate to facilitate fetal descent?
- A. Encourage the mother to push forcefully during contractions.
- B. Apply fundal pressure to assist with fetal descent.
- C. Prepare for immediate cesarean section.
- D. Administer intravenous magnesium sulfate for uterine relaxation.
Correct Answer: B
Rationale: In the scenario of a woman in active labor experiencing a prolonged second stage with inadequate expulsive efforts, the appropriate nursing intervention to facilitate fetal descent would be to apply fundal pressure. Fundal pressure, or applying pressure on the upper abdomen just above the uterine fundus, can help in directing the fetal head downwards and aiding in the descent through the birth canal. It is important to note that fundal pressure should be applied carefully and with proper technique to prevent excessive force that could potentially harm the mother or the baby. Encouraging the mother to push forcefully during contractions can be helpful, but the addition of fundal pressure can provide extra assistance in cases of inadequate progress. Immediate cesarean section may be considered if other interventions are unsuccessful or if there are concerns for fetal distress. Administering intravenous magnesium sulfate for uterine relaxation is not indicated in this situation.
What IMMEDIATE danger should the nurse anticipate post Transurethral Resection of the Prostate (TURP)?
- A. Infection
- B. Thrombosis
- C. Bleeding
- D. Shock
Correct Answer: C
Rationale: Post Transurethral Resection of the Prostate (TURP), the immediate danger that the nurse should anticipate is bleeding. TURP is a surgical procedure that involves removing portions of the prostate gland through the urethra. Due to the nature of the surgery and the rich blood supply to the prostate, bleeding is a common complication post-TURP. Excessive bleeding can lead to hypovolemic shock, which is a life-threatening condition. Therefore, monitoring for signs of bleeding, such as blood in the urine, drop in hematocrit levels, hypotension, tachycardia, and signs of hypovolemic shock, is crucial to prevent any serious complications. Proper assessment, monitoring, and timely intervention are essential in managing post-TURP bleeding and preventing adverse outcomes.
After the successful vaginal1 delivery, medication was ordered to be given immediately. The supervisor reassured the newly hired nurse that everything will be fine because the medication will
- A. promote vasoconstriction of uterine muscles
- B. hasten uterine contractility and control bleeding
- C. facilitate the return of pre pregnancy vital signs
- D. promote vasodilation of uterine muscles
Correct Answer: B
Rationale: The medication given after a successful vaginal delivery that helps to hasten uterine contractility and control bleeding is typically an oxytocic agent, such as oxytocin. Oxytocin helps the uterus to contract effectively, which is important for preventing excessive bleeding after delivery. This medication is commonly used in the postpartum period to help the uterus return to its normal size and position. The supervisor reassured the newly hired nurse that everything will be fine because this medication will help promote uterine contractions and control bleeding, which are crucial steps in the postpartum management.
A patient in the ICU develops acute respiratory distress syndrome (ARDS) with severe hypoxemia refractory to conventional oxygen therapy. What intervention should the healthcare team prioritize to improve the patient's oxygenation?
- A. Initiate prone positioning to optimize lung recruitment.
- B. Administer inhaled pulmonary vasodilators for vasodilation.
- C. Perform recruitment maneuvers to open collapsed alveoli.
- D. Recommend extracorporeal membrane oxygenation (ECMO) for respiratory support.
Correct Answer: D
Rationale: In the scenario described, the patient is experiencing severe hypoxemia refractory to conventional oxygen therapy, indicating a need for advanced respiratory support. When a patient with ARDS fails to respond to conservative management, including mechanical ventilation strategies, prone positioning, and recruitment maneuvers, the next step may involve extracorporeal membrane oxygenation (ECMO). ECMO provides a way to bypass the lungs and oxygenate the blood directly, allowing for enhanced gas exchange and support for severely compromised respiratory function. Therefore, in this critical situation, prioritizing the recommendation for ECMO can offer the patient the best chance of improving oxygenation and survival.