Nokea
Which of the following actions is recommended for managing a patient with a suspected snakebite?
- A. Applying a tourniquet proximal to the bite site.
- B. Immobilizing the affected limb at the level of the heart.
- C. Making an incision over the bite site to facilitate venom extraction.
- D. Transporting the patient to a medical facility for antivenom administration.
Correct Answer: D
Rationale: The correct answer is D: Transporting the patient to a medical facility for antivenom administration. This is recommended because antivenom is the definitive treatment for snakebites. Tourniquets (choice A) can worsen tissue damage and should be avoided. Elevating the limb (choice B) may not prevent venom spread. Making an incision (choice C) can lead to infection and increased venom absorption. Antivenom administration at a medical facility is crucial for proper management of snakebites.
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A patient with a history of stroke is prescribed clopidogrel (Plavix) for secondary prevention of thrombotic events. Which laboratory test should the nurse monitor closely during clopidogrel therapy?
- A. Prothrombin time (PT)
- B. Activated partial thromboplastin time (aPTT)
- C. Platelet count
- D. International normalized ratio (INR)
Correct Answer: C
Rationale: The correct answer is C: Platelet count. Platelet count should be monitored closely during clopidogrel therapy because it works by inhibiting platelet aggregation, reducing the risk of clot formation. Monitoring platelet count helps assess the drug's effectiveness and prevent potential complications like bleeding or clotting events. Prothrombin time (A), activated partial thromboplastin time (B), and international normalized ratio (D) are tests that primarily assess the coagulation factors and are not directly affected by clopidogrel therapy, making them less relevant for monitoring this specific medication.
A nurse is conducting a discharge planning assessment for a patient preparing to transition home. What action by the nurse demonstrates continuity of care?
- A. Providing the patient with written discharge instructions only
- B. Discharging the patient without coordinating follow-up care or support services
- C. Communicating with the patient's primary care provider and community resources
- D. Disregarding the patient's concerns and preferences during the discharge process Specialized Nursing Procedures
Correct Answer: C
Rationale: The correct answer is C because communicating with the patient's primary care provider and community resources demonstrates continuity of care. This action ensures a seamless transition from the hospital to home by keeping all involved parties informed and involved in the patient's care. Option A (written discharge instructions only) may provide information but lacks coordination with other healthcare providers. Option B (discharging without follow-up care coordination) can lead to gaps in care. Option D (disregarding patient concerns) goes against patient-centered care and can disrupt the continuity of care.
In the presentation of results of qualitative research, the nurse researcher uses as a reference in the write-up the
- A. first
- B. fourth
- C. second
- D. third
Correct Answer: C
Rationale: The correct answer is C: second. In qualitative research, the nurse researcher typically uses the second person as a reference in the write-up to maintain objectivity and convey findings accurately. Using "first" may introduce bias, "fourth" is irrelevant, and "third" is too far removed from the perspective of the researcher. By referencing the second person, the researcher can present the results in a clear and unbiased manner, enhancing the credibility of the study.
A pregnant woman presents with severe abdominal pain and passage of tissue at 12 weeks gestation. On examination, the cervix is partially dilated, and products of conception are protruding through the cervical os. Which of the following conditions is the most likely cause of these symptoms?
- A. Ectopic pregnancy
- B. Incomplete abortion
- C. Placenta previa
- D. Gestational trophoblastic disease
Correct Answer: B
Rationale: In this scenario, the pregnant woman is presenting with severe abdominal pain, passage of tissue, and cervical dilation with products of conception protruding through the cervical os at 12 weeks gestation. These are classic signs and symptoms of an incomplete abortion. Incomplete abortion occurs when not all of the products of conception are expelled from the uterus. It can present with vaginal bleeding, abdominal pain, cervical dilation, and passage of tissue. The management of incomplete abortion may involve expectant, medical, or surgical options depending on the clinical context and the patient's condition.
A postpartum client presents with persistent, severe perineal pain and swelling following a vaginal delivery. On assessment, the nurse notes ecchymosis and tenderness of the perineum. Which nursing action is most appropriate?
- A. Applying ice packs to the perineum for pain relief
- B. Encouraging the client to sit on a donut cushion
- C. Notifying the healthcare provider immediately
- D. Administering additional analgesic medication
Correct Answer: C
Rationale: The most appropriate nursing action in this situation is to notify the healthcare provider immediately. The client presenting with persistent, severe perineal pain and swelling, along with ecchymosis and tenderness of the perineum, could be indicative of complications such as a perineal hematoma. A perineal hematoma is a collection of blood in the perineal tissues and can be a serious postpartum complication requiring prompt medical attention. Therefore, it is crucial to alert the healthcare provider so that appropriate assessment, management, and treatment can be initiated promptly. Applying ice packs or encouraging the client to sit on a donut cushion may not be sufficient in this situation, and administering additional analgesic medication should be done only after the healthcare provider has assessed and determined the cause of the symptoms.