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A woman in active labor is diagnosed with postpartum hemorrhage (PPH) due to uterine atony. What is the priority nursing intervention?
- A. Massage the uterus to promote contraction.
- B. Prepare for immediate blood transfusion.
- C. Administer intravenous antibiotics.
- D. Elevate the mother's legs to promote venous return.
Correct Answer: A
Rationale: The priority nursing intervention for a woman in active labor diagnosed with postpartum hemorrhage (PPH) due to uterine atony is to massage the uterus to promote contraction. Uterine massage helps to stimulate uterine muscle tone and contraction, which can help control bleeding by reducing the size of blood vessels and promoting hemostasis. It is important to address the uterine atony promptly to prevent further blood loss and stabilize the patient's condition. Other interventions such as blood transfusion, administering antibiotics, and elevating the mother's legs can be considered based on the patient's response to the initial intervention of uterine massage.
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A nurse involves well-being in her definition of health. What will the primary concern or focus of the nurse when she provides care to a family confronting the imminent death of a family member?
- A. Reinforcing the need for the whole family to adapt to the impending death.
- B. Sharing the nurse's knowledge on the client's symptoms of grief
- C. Discussing the perceived meaning of life with the family
- D. Administering pain medication so that the client can be kept comfortable
Correct Answer: A
Rationale: When a nurse involves well-being in her definition of health, it indicates a holistic approach that considers not only physical health but also emotional, mental, and social aspects of well-being. In the context of a family confronting the imminent death of a family member, the primary concern of the nurse would be to focus on reinforcing the need for the whole family to adapt to the impending death. This involves providing emotional support, facilitating communication, addressing coping mechanisms, and assisting the family in coming to terms with the situation. By emphasizing the importance of the whole family adapting to the imminent death, the nurse can help promote holistic well-being for the family during this challenging time.
The toddlers years are a time of great cognitive, emotional and social development. The toddles is a child _______ months old.
- A. 6 to 12
- B. 36 to 48
- C. 9 to 36
- D. 12 to 36
Correct Answer: C
Rationale: Toddlers are typically children who are 1 to 3 years old. In this context, the toddlers are children in the age range of 9 to 36 months old. This period is marked by significant cognitive, emotional, and social development as children in this age group start to explore their environments, develop their language skills, begin to understand emotions, and interact with others. It is a crucial stage in a child's development where they start becoming more independent and forming their own identities.
A patient presents with crushing chest pain that lasts longer than 20 minutes, diaphoresis, and dyspnea. An electrocardiogram (ECG) shows ST-segment elevation in the anterior leads. Which cardiovascular disorder is most likely responsible for these symptoms?
- A. Stable angina
- B. Unstable angina
- C. Acute myocardial infarction
- D. Prinzmetal's angina
Correct Answer: C
Rationale: The patient is most likely experiencing an acute myocardial infarction (MI) based on the presentation of crushing chest pain lasting longer than 20 minutes, diaphoresis, dyspnea, and ST-segment elevation on the ECG. These symptoms are consistent with the classic presentation of an ST-segment elevation myocardial infarction (STEMI), which is a type of acute MI that is characterized by prolonged ischemia leading to myocardial cell death. In this case, the ST-segment elevation in the anterior leads indicates myocardial damage in the corresponding area of the heart supplied by the affected coronary artery. This is a medical emergency that requires urgent intervention to restore blood flow to the affected myocardium and prevent further complications.
The INITIAL priority assessment performed by the nurse, when admitting a patients the unit after abdominal surgery is to check for ______.
- A. surgical site for drainage and hemorrhage
- B. skin color and temperature
- C. responsiveness to painful stimuli and noise
- D. respiratory function and airway
Correct Answer: D
Rationale: When admitting a patient to the unit after abdominal surgery, the initial priority assessment performed by the nurse should focus on assessing the patient's respiratory function and airway. This is crucial because post-surgical patients are at risk for complications such as respiratory depression, atelectasis, and airway obstruction. Monitoring the patient's breathing pattern, oxygen saturation levels, and ensuring a patent airway are essential in preventing respiratory distress or failure. Prompt assessment and intervention in this area can help prevent respiratory complications and ensure the patient's safety and well-being. Once the patient's respiratory status is stable, the nurse can then proceed to assess other aspects such as the surgical site, skin color, temperature, and responsiveness to stimuli.
A nurse administers the wrong medication to a patient and the patient is harmed. The physician who ordered the medication did not read the documentation that the patient was allergic to the drug. Which statement is true regarding liability for the administration of the wrong medication?
- A. The nurse is not responsible, because the nurse was merely following the doctor's orders.
- B. Only the nurse is responsible, because the nurse actually administered the medication.
- C. Only the physician is responsible, because the physician actually ordered the drug.
- D. Both the nurse and the physician are responsible for their respective actions.
Correct Answer: D
Rationale: In a situation where a nurse administers the wrong medication to a patient resulting in harm, both the nurse and the physician can be held liable for their respective roles in the error. The nurse is responsible for administering the incorrect medication, which is a violation of their duty to provide safe and appropriate care. However, the physician is also responsible because they failed to review the patient's documentation indicating the allergy to the medication before ordering it. As healthcare professionals, both the nurse and the physician have a duty of care to ensure patient safety, and in this case, both individuals failed in their responsibilities, leading to the harm caused to the patient. Therefore, both the nurse and the physician can be held accountable for the error.