Nokea
Nurse Selma is preparing to administer ofloxacin eardrop on Catherine per Doctor's order. She needs to hold the bottle with her hands to warm up the solution to prevent dizziness for
- A. 5-6 minutes
- B. 1 to 2 minutes
- C. 3-4 minutes
- D. 6-7 minutes
Correct Answer: B
Rationale: Warming up ofloxacin eardrops before administering is done to prevent dizziness, which can occur if a cold solution is placed in the ear. Holding the bottle with hands for about 1 to 2 minutes is usually sufficient to warm up the solution to a comfortable temperature for the patient. Warming the solution for too long, such as 5-6 minutes, may not be necessary and could potentially waste time. So, the correct duration for warming up ofloxacin eardrops is 1 to 2 minutes.
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A postpartum client who experienced a perineal laceration reports pain and discomfort during defecation. What nursing intervention should be prioritized to alleviate symptoms?
- A. Recommending the use of stool softeners or laxatives
- B. Encouraging the client to increase fluid and fiber intake
- C. Providing perineal care using peri-bottles with warm water
- D. Instructing the client on proper positioning for defecation
Correct Answer: A
Rationale: The priority nursing intervention for a postpartum client who experienced a perineal laceration and reports pain and discomfort during defecation is to recommend the use of stool softeners or laxatives. Perineal lacerations can lead to pain and discomfort during bowel movements due to the strain that passing stools may cause on the tender area. Stool softeners or laxatives can help soften the stool, making it easier and less painful for the client to have bowel movements. It is important to alleviate the discomfort and promote bowel regularity to prevent complications such as constipation, which can further exacerbate the pain and delay healing of the perineal laceration.
After instructing a primiparous patient about episiotomy care, which of the following indicates successful teaching?
- A. "I will wipe the area from front to back using blotting motion "
- B. "I will put ice packs on the site 15 minutes once a day for 3 to 4 days"
- C. "Before bedtime, I will do a cold water sitz bath"
- D. "I'll use sudsy water to clean the episiotomy"
Correct Answer: A
Rationale: Wiping the episiotomy area from front to back using a blotting motion helps prevent introducing bacteria from the rectal area to the vaginal area, reducing the risk of infection. This technique also avoids causing unnecessary trauma to the healing tissues. Ensuring proper hygiene is vital to prevent complications such as infection, which is crucial for the healing process after an episiotomy.
A nurse is preparing to assist with a bone marrow biopsy procedure for a patient. What action should the nurse prioritize to ensure patient comfort during the procedure?
- A. Administering intravenous sedation to the patient before the biopsy
- B. Providing distraction techniques such as music or relaxation exercises
- C. Applying a topical anesthetic cream to the biopsy site
- D. Allowing the patient to eat or drink up to one hour before the procedure
Correct Answer: C
Rationale: Prioritizing the application of a topical anesthetic cream to the biopsy site is essential to ensure patient comfort during the bone marrow biopsy procedure. This will help numb the area where the biopsy needle will be inserted, reducing the pain and discomfort experienced by the patient. Administering intravenous sedation may not always be needed for a bone marrow biopsy and should be decided by the healthcare provider based on the patient's individual needs. Providing distraction techniques such as music or relaxation exercises can be helpful, but they may not be as effective at reducing the physical discomfort caused by the procedure. Allowing the patient to eat or drink up to one hour before the procedure is important for other reasons, such as preventing potential complications during sedation or anesthesia, but it is not directly related to ensuring comfort during the biopsy itself.
A patient receiving palliative care for end-stage heart failure experiences severe fatigue and limited mobility. What intervention should the palliative nurse prioritize to promote the patient's comfort and quality of life?
- A. Recommend initiating physical therapy to improve mobility and strength.
- B. Encourage the patient to conserve energy and avoid unnecessary activities.
- C. Prescribe stimulant medications to alleviate fatigue and increase energy levels.
- D. Refer the patient to a nutritionist for dietary modifications to boost energy.
Correct Answer: B
Rationale: In this scenario, the palliative nurse should prioritize encouraging the patient to conserve energy and avoid unnecessary activities (Option B). End-stage heart failure can lead to severe fatigue and limited mobility, making it essential for the patient to conserve energy to prevent exacerbating symptoms and improve quality of life. Engaging in physical therapy (Option A) may not be suitable for a patient experiencing severe fatigue, as it can further drain energy reserves. Prescribing stimulant medications (Option C) may have limited effectiveness and potential side effects. Referring the patient to a nutritionist for dietary modifications (Option D) is important for overall health but may not directly address the immediate comfort and quality of life concerns related to fatigue and limited mobility. Helping the patient prioritize energy conservation will allow them to use their limited energy for essential activities, leading to a more comfortable and fulfilling experience while receiving palliative care for end-stage heart failure.
A 45-year-old woman presents with heavy menstrual bleeding and iron deficiency anemia. On pelvic examination, the uterus is enlarged, and multiple irregularly shaped masses are palpated. Which condition is most likely to be responsible for these findings?
- A. Leiomyomas (uterine fibroids)
- B. Endometrial hyperplasia
- C. Endometrial polyps
- D. Adenomyosis
Correct Answer: A
Rationale: The clinical presentation of heavy menstrual bleeding, iron deficiency anemia, an enlarged uterus, and irregularly shaped masses palpated on pelvic examination is most indicative of leiomyomas, also known as uterine fibroids. Leiomyomas are benign smooth muscle tumors that commonly occur in women of reproductive age. They can lead to heavy menstrual bleeding and iron deficiency anemia due to their size and location within the uterus. On pelvic examination, leiomyomas can be felt as irregularly shaped masses within the uterine wall. This presentation is classic for leiomyomas and distinguishes them from conditions such as endometrial polyps, endometrial hyperplasia, and adenomyosis.