Nokea
During the normal postpartum course, when would the nurse expect to note the fundal assessment that will be in line with the umbilicus?
- A. Immediately after the delivery
- B. 4 days after the delivery
- C. When the client's bladder is full
- D. The day after the delivery
Correct Answer: D
Rationale: After childbirth, the uterus undergoes involution, which is the process of returning to its pre-pregnant size and location. Initially, the fundus is firm and located at or just below the level of the umbilicus immediately after delivery. Over the next 24 hours, the fundus should gradually decrease in height as involution progresses. By the day after delivery, the nurse would expect the fundal assessment to be in line with the umbilicus or slightly below it, indicating normal involution of the uterus. If the fundus remains high or deviates from this expected progression, further assessment and intervention may be needed to prevent complications such as postpartum hemorrhage.
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Ramon died at 10:00 PM. His father cried much and refused to move Ramon 's body. What is the APPROPRIATE approach of the nurse?
- A. Talk about the reality of death.
- B. Leave the mother and the child for the last time.
- C. Silence to allow the mother to grieve.
- D. Cry with the mother as you remember your own experience of death in family.
Correct Answer: A
Rationale: The appropriate approach of the nurse in this situation would be to talk about the reality of death with the father. It is important to provide appropriate and compassionate communication, acknowledging the father's grief while also gently guiding him towards accepting the reality of the situation. By discussing the reality of death and offering support, the nurse can help the father start the grieving process and eventually come to terms with the loss of his son. It is important to provide emotional support and guidance in a sensitive and respectful manner during such a difficult time.
A patient with a severe fungal infection demonstrates impaired neutrophil function. Which of the following cellular processes is most likely to be affected in this patient?
- A. Phagocytosis
- B. Antibody production
- C. Cytokine secretion
- D. Mast cell degranulation
Correct Answer: A
Rationale: Neutrophils are a type of white blood cell that play a crucial role in immune defense against pathogens, particularly in phagocytosis - the process by which they engulf and destroy invading microorganisms. In a severe fungal infection, impaired neutrophil function would most likely affect their ability to effectively perform phagocytosis, leading to a compromised immune response against the fungal pathogen. This would result in increased susceptibility to the infection and potentially severe outcomes for the patient. Antibody production, cytokine secretion, and mast cell degranulation are important components of the immune response, but neutrophils are primarily responsible for phagocytosis in the innate immune system.
A patient presents with recurrent episodes of epistaxis, particularly after blowing the nose or during dry weather. Anterior rhinoscopy reveals a friable, vascular lesion in Little's area. Which of the following interventions is most appropriate for managing this condition?
- A. Nasal packing with anterior nasal tampons
- B. Application of silver nitrate cautery
- C. Endoscopic cauterization of the sphenopalatine artery
- D. Surgical excision of the nasal polyp
Correct Answer: B
Rationale: The clinical scenario described is consistent with a diagnosis of anterior epistaxis due to a prominent vascular lesion located in Little's area, which is an important site for nosebleeds. Silver nitrate cautery is the most appropriate intervention for managing this condition. Silver nitrate cautery is a commonly used method to chemically cauterize and eliminate the friable blood vessels responsible for recurrent epistaxis. It is a cost-effective and minimally invasive technique that can be easily performed in an outpatient setting. Nasal packing with anterior nasal tampons might be considered in cases of severe or refractory epistaxis, but in this scenario, where the source of bleeding is localized and identifiable, silver nitrate cautery is the treatment of choice. Endoscopic cauterization of the sphenopalatine artery and surgical excision of a nasal polyp are unnecessary and overly invasive for the described scenario.
What response should the nurse use in dealing with this behavior?
- A. Encourage her to scrub the doorknobs with a strong antiseptic so she does not need to use tissue papers.
- B. Supply her with paper tissue to help her function until her anxiety is reduced .
- C. Force her to touch doorknobs by removing all available paper tissue until she learns to deal with the situation.
- D. Explain to her that ideas about doorknobs with covid 19 are part of the i1lness and is not necessary.
Correct Answer: B
Rationale: Supplying the patient with paper tissues to use when touching doorknobs is the most appropriate response in this situation. This action acknowledges and respects the patient's anxiety while providing a practical solution to help her cope. Forcing her to touch doorknobs or discouraging her concerns would not address the underlying anxiety and may lead to increased distress. Encouraging her to scrub doorknobs with a strong antiseptic is not necessary and may exacerbate her anxiety. Explaining that her concerns are part of her illness may invalidate her feelings and is not a constructive way to address the situation. Supplying her with paper tissues allows her to feel more comfortable while still being able to navigate her daily activities.
The patient has been ordered a regimen to treat a urinary tract infection and notifies the nurse that the patient's urine has turned an orange color. The nurse recognizes that the patient is most likely being treated with which drug?
- A. Ciprofloxacin (Cipro)
- B. Darifenacin hydrobromide (Enablex)
- C. Bethanechol Cl (Urecholine))
- D. Phenazopyridine HCl (Pyridium)
Correct Answer: D
Rationale: Phenazopyridine HCl (Pyridium) is a medication commonly used to relieve the pain, burning, and discomfort associated with urinary tract infections (UTIs). One of the notable side effects of Phenazopyridine is the discoloration of urine, turning it a rusty-red or orange color. This color change is harmless and temporary, but it can be alarming to patients who are unaware of this side effect. Therefore, if a patient undergoing treatment for a UTI notices their urine has turned orange, it is most likely due to the administration of Phenazopyridine.