Nokea
The nurse explains to the mother that the uterus will return to its pre pregnancy state in _____ weeks.
- A. Six
- B. Three
- C. Four
- D. five
Correct Answer: C
Rationale: The nurse explains to the mother that the uterus will return to its pre-pregnancy state in about four to six weeks after giving birth. This timeframe is an average estimation of how long it takes for the uterus to shrink back to its normal size and position after going through the process of supporting and nourishing a developing fetus. The process of the uterus returning to its pre-pregnancy state is known as involution, where the uterus undergoes contractions to shed the excess lining and reduce in size. This period is crucial for the body to heal and recover from the changes that occurred during pregnancy and childbirth.
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A patient admitted to the ICU develops acute exacerbation of chronic heart failure (CHF) with pulmonary edema and respiratory distress. What intervention should the healthcare team prioritize to manage the patient's exacerbation?
- A. Administer intravenous loop diuretics for fluid removal.
- B. Initiate positive pressure ventilation for respiratory support.
- C. Perform emergent pericardiocentesis for tamponade relief.
- D. Recommend inotropic medications to improve myocardial contractility.
Correct Answer: B
Rationale: In this scenario, the patient is presenting with acute exacerbation of chronic heart failure (CHF) complicated by pulmonary edema and respiratory distress. The priority intervention for managing this exacerbation is to initiate positive pressure ventilation for respiratory support. Positive pressure ventilation, such as non-invasive positive pressure ventilation (NIPPV) or invasive mechanical ventilation, can help improve oxygenation and decrease the work of breathing for the patient. By providing adequate respiratory support, ventilation can reduce the negative effects of pulmonary edema and respiratory distress due to CHF exacerbation. Administering intravenous loop diuretics (Choice A) might be necessary to address fluid overload, but it is not the initial priority as ensuring adequate ventilation is crucial. Emergent pericardiocentesis (Choice C) is not indicated in this scenario as there is no mention of cardiac tamponade. Inotropic medications (Choice D) may be considered in managing acute exacerbation of CHF but
A patient expresses fear of needles before a scheduled blood draw. What is the nurse's best approach to address this fear?
- A. Dismiss the patient's fear and proceed with the blood draw.
- B. Provide the patient with information about relaxation techniques and distraction methods.
- C. Ignore the patient's fear and proceed with the blood draw quickly.
- D. Tell the patient that fear of needles is irrational and unfounded.
Correct Answer: B
Rationale: The nurse's best approach to address the patient's fear of needles before a blood draw is to provide the patient with information about relaxation techniques and distraction methods (Option B). Dismissing the patient's fear (Option A), ignoring the fear and proceeding quickly (Option C), or telling the patient that the fear is irrational and unfounded (Option D) would not be helpful and could potentially escalate the patient's anxiety. Providing information on relaxation techniques such as deep breathing or visualization, as well as distraction methods like listening to music or engaging in conversation, can help the patient feel more comfortable and reduce their fear and anxiety during the blood draw procedure. It is important for the nurse to acknowledge and address the patient's concerns in a supportive and empathetic manner to build trust and ensure a successful blood draw experience.
In order to PREVENT the spread of Scabies infestation to other residents in the community, Nurse Emma should teach the family, which of the following?
- A. Boil the utensils used by the patients
- B. Avoid sharing items used by the infected person.
- C. Take a bath three or more times a day.
- D. Wear mask and shield at all times even at home.
Correct Answer: B
Rationale: The correct answer is to avoid sharing items used by the infected person in order to prevent the spread of Scabies infestation to other residents in the community. Scabies is a highly contagious skin infestation caused by the Sarcoptes scabiei mite, and it can easily spread through direct skin-to-skin contact or by sharing personal items such as clothing, towels, and bedding. By advising the family to avoid sharing items used by the infected person, Nurse Emma is helping to prevent the transmission of the mites to others in the community. Boiling utensils, taking excessive baths, or wearing masks and shields are not necessary preventive measures for scabies infestation.
What is the ultimate purpose of record keeping
- A. Safeguard information
- B. History
- C. Archive
- D. Store information
Correct Answer: A
Rationale: The ultimate purpose of record-keeping is to safeguard information. While history, archiving, and storing information are all important functions of record-keeping, safeguarding information stands out as the primary goal. Keeping accurate and accessible records ensures that essential information is secured, protected from unauthorized access, loss, and damage. Safeguarding information also promotes transparency, accountability, and compliance with legal and ethical standards. In the case of Nurse Mely's consideration of teamwork and collaboration in community health nursing, safeguarding the relevant information through precise and organized record-keeping is crucial for effective communication, continuity of care, and successful health outcomes.
Which of the following nursing measures would the nurse LEAST CONSIDERS to Patient Ellie with oxytocin drip?
- A. Know, how to recognize potential adverse reactions:
- B. Administer oxytocin drug with caution
- C. Monitor patient closely when infusing oxytocin
- D. Inform patient about potential complications.
Correct Answer: D
Rationale: While all of the nursing measures listed are important considerations when managing a patient receiving oxytocin drip, the nurse would least consider informing the patient about potential complications. The reason for this is that it is the responsibility of the healthcare provider (such as the physician or advanced practice nurse) to inform the patient about potential complications of a medication or treatment. Nurses are instrumental in providing education and support to patients, but in the case of informing patients about potential complications, this task typically falls under the purview of the prescribing provider. The primary focus of the nurse in this situation would be to assess, administer, monitor, and educate the patient as appropriate, ensuring safe and effective care delivery.