Nokea
During the implementation process, the nurse should ensure a better assimilation of the teachings.
- A. serious lecturer
- B. conducive time and place
- C. Lecture to start at 11:00AM
- D. neophyte as sharer
Correct Answer: B
Rationale: Creating a conducive time and place for the teachings is crucial during the implementation process to ensure better assimilation by the staff. By choosing a suitable time that does not clash with other responsibilities and providing a comfortable environment for learning, the nurse can enhance the staff's understanding and retention of the teachings. This approach helps in engaging the staff effectively and facilitating a productive learning experience.
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A woman in active labor presents with prolonged second stage, characterized by ineffective pushing efforts and slow fetal descent. What maternal condition should the nurse assess for that may contribute to this abnormal labor pattern?
- A. Pelvic floor dysfunction
- B. Maternal fatigue
- C. Fetal macrosomia
- D. Uterine hyperstimulation
Correct Answer: A
Rationale: Pelvic floor dysfunction can contribute to a prolonged second stage of labor by impairing the ability of the woman to effectively push during contractions. This can result in inefficient pushing efforts and slow fetal descent. The nurse should assess for signs and symptoms of pelvic floor dysfunction, such as difficulty controlling bowel movements or urine leakage, as addressing this issue may help improve the progress of labor. Maternal fatigue, fetal macrosomia (larger than average baby size), and uterine hyperstimulation are other factors that can impact labor but are less likely to specifically contribute to ineffective pushing efforts and slow fetal descent in the second stage of labor.
The nurse assists a health care provider in performing a liver biopsy. After the biopsy, the nurse should place the client in which position?
- A. Prone
- B. Supine
- C. A left side-lying position with a small pillow or folded towel under the puncture site
- D. A right side-lying position with a small pillow or folded towel under the puncture site
Correct Answer: C
Rationale: Placing the client in a left side-lying position after a liver biopsy helps to promote pressure on the puncture site, which can reduce the risk of bleeding. Placing a small pillow or folded towel under the puncture site provides additional support and helps to maintain pressure on the area. This position also helps prevent the client from putting pressure on the abdomen, which could potentially affect the biopsy site and increase the risk of bleeding or complications. Overall, positioning the client on the left side with support under the puncture site is the most appropriate and safest option after a liver biopsy.
Nurse Edna admits a patient from the ER to the medical unit. The patient is very restless with IV lines and a urinary catheter. She was put to bed and the nurse applied a body restraint without the doctor's order. Nurse Edna's action can be liable for _____.
- A. invasion of privacy
- B. battery
- C. assault
- D. neglect
Correct Answer: B
Rationale: Battery in the context of healthcare refers to the intentional and unauthorized touching of a patient. By applying a body restraint without a doctor's order, Nurse Edna has potentially committed battery against the patient. It is important for healthcare providers to obtain proper authorization before implementing any physical restraints on a patient to avoid legal liabilities such as battery.
A patient is prescribed a loop diuretic for the management of heart failure. Which electrolyte imbalance is most commonly associated with loop diuretic therapy?
- A. Hypercalcemia
- B. Hypokalemia
- C. Hypernatremia
- D. Hypomagnesemia
Correct Answer: B
Rationale: Loop diuretics such as furosemide are commonly prescribed for the management of heart failure to reduce fluid overload and lower blood pressure by increasing the excretion of sodium and water. These medications promote the loss of potassium through increased urinary output. Hypokalemia, or low potassium levels in the blood, is the most common electrolyte imbalance associated with loop diuretic therapy. Potassium is an essential electrolyte for proper functioning of the heart, muscles, and nerves. Low potassium levels can lead to symptoms such as muscle weakness, cramps, and potentially life-threatening cardiac arrhythmias. Patients on loop diuretics are often monitored for potassium levels, and sometimes potassium supplements may be prescribed to prevent or correct hypokalemia.
In planning the nursing care for this patient what is the important nursing intervention a nurse must do?
- A. Encourage patient to release anxiety by crying.
- B. Reassure family that complete recovery is probable.
- C. Assess patient for respiratory distress.
- D. Have patient assist with care.
Correct Answer: C
Rationale: Assessing the patient for respiratory distress is the important nursing intervention that must be done in this situation. The scenario provided indicates that the patient with chronic obstructive pulmonary disease (COPD) is experiencing increased work of breathing, which puts them at risk for respiratory distress. It is crucial for the nurse to monitor the patient's respiratory status closely, including assessing their oxygen saturations, respiratory rate, and effort, to identify any signs of respiratory distress early and intervene promptly. This proactive assessment can help prevent further deterioration of the patient's condition and ensure appropriate nursing interventions are implemented promptly.