Nokea
Upon seeing warning signs of child abuse, the BEST nursing action that Nurse Alma should make is to report the noted observation to __________.
- A. Dept of Social Welfare Development (DSWD)
- B. Headnurse
- C. Philippine National Police (PNP)
- D. Attending Pediatrician
Correct Answer: A
Rationale: Reporting observed signs of child abuse to the Department of Social Welfare Development (DSWD) is the best nursing action in cases of suspected child abuse. DSWD is the government agency tasked with protecting the welfare of children and families. They have the necessary authority and resources to investigate and intervene in cases of child abuse. Reporting to DSWD ensures that professional social workers and experts will step in to assess the situation, provide necessary interventions, and ensure the safety of the child. It is important to involve the appropriate authorities who are trained to handle cases of child abuse effectively. Reporting to the DSWD helps in safeguarding the well-being of the child and taking the necessary steps to address the situation appropriately.
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For this patient who is to undergo surgery (closure of the sac), what would be the PRIORITY nursing diagnosis? It is risk for __________.
- A. Activity intolerance
- B. Infection
- C. Respiration
- D. Altered growth and development
Correct Answer: B
Rationale: The priority nursing diagnosis for a patient undergoing surgery (closure of the sac) would be risk for infection. This is because surgical procedures increase the risk of infection due to the breach in the skin and introduction of microorganisms. Infection can lead to serious complications, delay healing, and prolong recovery time. Therefore, prevention, early detection, and prompt treatment of infections are essential in the perioperative period to ensure the best possible outcomes for the patient.
A nurse is preparing to assist with a cardiopulmonary resuscitation (CPR) procedure for a patient in cardiac arrest. What action should the nurse prioritize during the initial assessment?
- A. Administering oxygen via nasal cannula at 2 liters per minute
- B. Checking for responsiveness and calling for help immediately
- C. Placing the patient in the recovery position to facilitate breathing
- D. Assessing the patient's airway, breathing, and circulation (ABCs)
Correct Answer: D
Rationale: The correct action to prioritize during the initial assessment when preparing to assist with a cardiopulmonary resuscitation (CPR) procedure for a patient in cardiac arrest is to assess the patient's airway, breathing, and circulation (ABCs). This involves quickly checking the patient's airway for any obstructions, assessing their breathing for signs of breathing difficulties or absence of breathing, and evaluating their circulation by checking for a pulse. This step is crucial in determining the need for immediate intervention, such as clearing the airway, providing rescue breaths, or initiating chest compressions. By prioritizing the assessment of the ABCs, the nurse can promptly identify and address life-threatening issues to improve the patient's chances of survival during a cardiac arrest situation.
A postpartum client exhibits signs of mastitis, including breast tenderness, erythema, and warmth. Which nursing action is most appropriate?
- A. Encouraging the client to continue breastfeeding
- B. Applying warm compresses to the affected breast
- C. Notifying the healthcare provider immediately
- D. Administering oral antibiotics as prescribed
Correct Answer: C
Rationale: Mastitis is an infection of the breast tissue that may occur in postpartum clients. When a postpartum client exhibits signs of mastitis, including breast tenderness, erythema, and warmth, it is crucial to notify the healthcare provider immediately. Prompt medical evaluation is necessary to determine the appropriate treatment plan, which may include antibiotics. Delay in treatment can lead to complications, such as abscess formation. Encouraging the client to continue breastfeeding and applying warm compresses may provide some relief but do not address the underlying infection. Administering oral antibiotics would require a prescription from the healthcare provider, hence notifying the provider is the most appropriate initial nursing action in this situation.
A patient in the ICU develops acute exacerbation of chronic kidney disease (CKD) with hyperkalemia and metabolic acidosis. What intervention should the healthcare team prioritize to manage the patient's metabolic derangements?
- A. Initiate intravenous sodium bicarbonate for acid-base correction.
- B. Administer insulin and glucose to promote cellular uptake of potassium.
- C. Recommend dietary potassium restriction and potassium-binding agents.
- D. Perform emergent hemodialysis for potassium removal.
Correct Answer: D
Rationale: In the scenario described, with the patient having an acute exacerbation of chronic kidney disease (CKD) leading to hyperkalemia and metabolic acidosis, the priority intervention to manage the metabolic derangements is to perform emergent hemodialysis for potassium removal. Hemodialysis is the most effective and rapid method to lower dangerously high potassium levels in the blood. It is crucial in cases of severe hyperkalemia where other measures such as medications or dietary modifications may not be sufficient or fast enough to correct the elevated potassium levels. Additionally, hemodialysis can also help in improving metabolic acidosis by removing waste products and excess electrolytes from the blood. Overall, emergent hemodialysis is the most appropriate intervention for managing the acute metabolic abnormalities in this critically ill patient.
A nurse is advocating for a patient's rights within the healthcare system. What action by the nurse demonstrates advocacy?
- A. Making decisions for the patient without their input
- B. Collaborating with the healthcare team to develop a care plan
- C. Encouraging the patient to follow the healthcare provider's orders
- D. Speaking up on behalf of the patient to ensure their needs are met
Correct Answer: D
Rationale: Speaking up on behalf of the patient to ensure their needs are met is a key action that demonstrates advocacy by the nurse. Advocacy involves actively supporting and safeguarding the rights of the patient, ensuring that their best interests are being considered within the healthcare system. This may include advocating for appropriate treatment, services, resources, or respect for the patient's autonomy and decision-making. By speaking up for the patient, the nurse is acting as their voice and championing their well-being.