Nokea
Elmo asks the nurse to explain his condition (BPH) Which statements are CORRECT explanations by the nurse? I It blocks the urethra. II It obstructs the bladder. III. It spreads to other parts of the body. IV. It leads to urinary retention
- A. I and IV
- B. I, II and III
- C. II, III, and IV
- D. I and III
Correct Answer: A
Rationale: I. It blocks the urethra: Benign Prostatic Hyperplasia (BPH) is a condition in which the prostate gland enlarges and can squeeze the urethra, leading to urinary symptoms such as difficulty urinating. This statement correctly explains one of the effects of BPH on the urinary system.
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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. assault
- C. battery
- D. neglect
Correct Answer: C
Rationale: Battery occurs when there is an intentional harmful or offensive contact with a person without their consent. In this scenario, Nurse Edna applied a body restraint to the patient without the doctor's order, which constitutes unauthorized physical contact. The patient did not give consent for the restraint, and Nurse Edna's action could be considered battery. It is important for healthcare providers to obtain proper authorization before using any form of physical restraint on a patient to avoid legal implications such as battery.
A patient presents with a thyroid nodule and signs of hyperthyroidism. Fine-needle aspiration biopsy reveals Hurthle cells and cellular atypia. Which endocrine disorder is most likely responsible for these symptoms?
- A. Hashimoto's thyroiditis
- B. Graves' disease
- C. Hurthle cell carcinoma
- D. Papillary thyroid carcinoma
Correct Answer: C
Rationale: Hurthle cell carcinoma is a type of thyroid cancer that arises from the Hurthle cells of the thyroid gland. Patients with Hurthle cell carcinoma may present with a thyroid nodule and signs of hyperthyroidism, which can mimic other thyroid disorders such as Graves' disease. Fine-needle aspiration biopsy revealing Hurthle cells and cellular atypia is suggestive of a Hurthle cell neoplasm, particularly Hurthle cell carcinoma. It is important to differentiate Hurthle cell carcinoma from benign Hurthle cell adenomas or other thyroid conditions to guide appropriate management and treatment.
Nurse Nora notices patient's uterine contractions are 70 seconds long and occur every 90 seconds when assessing the frequency of her contractions after she receives oxytocin. what would be the nurse's FIRST action?
- A. Give an emergency bolus of oxytocin to relaxed the uterus
- B. Discontinue the administration of the oxytocin infusion
- C. Increase the rate of client's IV infusion
- D. Ask client to turn to her left side and breathe deeply
Correct Answer: B
Rationale: Patient's uterine contractions lasting 70 seconds and occurring every 90 seconds signify hyperstimulation, which can be a serious complication associated with oxytocin administration. This may result in decreased uterine perfusion, fetal distress, and other adverse effects. The first action should be to discontinue the oxytocin infusion to prevent further complications and allow the uterus to relax. Observations and assessment should continue to monitor the patient's condition and response after discontinuing the infusion. Giving an emergency bolus of oxytocin or increasing the IV infusion rate would exacerbate the hyperstimulation, and turning the client to her left side and breathing deeply would not address the underlying issue of oxytocin-induced hyperstimulation.
To remove the ingested poisonous substance, the physician ordered a gastric lavage. What is the role of the nurse immediately prior to the procedure?
- A. Get the right size of the nasogastric tube
- B. Remind parents to be careful next time
- C. Obtain an informed consent immediately
- D. Tell the parent that they are negligent
Correct Answer: A
Rationale: Prior to a gastric lavage procedure, it is essential for the nurse to ensure the correct size of the nasogastric tube is selected. The appropriate size of the tube will allow for effective removal of the ingested poisonous substance during the procedure. Proper sizing also helps in preventing complications such as injury to the gastrointestinal tract or inadequate removal of the substance. This step is crucial for the safe and successful completion of gastric lavage. Reminding parents to be careful, obtaining informed consent immediately, or accusing them of negligence are not immediate responsibilities of the nurse in this context.
While preparing the operating room (OR) for a surgical procedure, the nurse notices that the surgical instrument tray is incomplete. What should the nurse do?
- A. Proceed with the procedure using the available instruments
- B. Document the missing instruments in the surgical count log
- C. Inform the sterile processing department and request additional instruments
- D. Borrow the missing instruments from another OR Professionalism and Fundamentals of Nursing
Correct Answer: C
Rationale: It is crucial to have a complete set of surgical instruments for any surgical procedure to ensure patient safety and the success of the surgery. If the nurse notices that the surgical instrument tray is incomplete, the best course of action is to inform the sterile processing department immediately. By doing so, the missing instruments can be promptly provided, ensuring that the surgical team has all the necessary tools for the procedure. Proceeding with the procedure using incomplete instruments can compromise patient safety and the quality of care provided. Documenting the missing instruments in the surgical count log is important for record-keeping purposes but should not delay the immediate action of requesting additional instruments. Borrowing instruments from another OR is not recommended as it can create confusion, potential cross-contamination, and disrupt the workflow of another surgical team.