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A postpartum client reports severe perineal pain and difficulty passing stools following a vaginal delivery. Which nursing intervention should be implemented?
- A. Administering a stool softener as ordered
- B. Encouraging the client to refrain from defecation until pain subsides
- C. Applying ice packs to the perineum for pain relief
- D. Providing education on proper perineal hygiene
Correct Answer: A
Rationale: Administering a stool softener as ordered is the most appropriate nursing intervention for a postpartum client experiencing severe perineal pain and difficulty passing stools following a vaginal delivery. Stool softeners help to soften the stool, making it easier for the client to pass without straining, which can exacerbate perineal pain. It is important to follow the healthcare provider's orders when administering medications to ensure proper dosing and effectiveness. Encouraging the client to refrain from defecation may lead to constipation and worsen the situation. Applying ice packs to the perineum can provide temporary pain relief, but addressing the underlying issue of constipation with a stool softener is more effective in the long term. Providing education on proper perineal hygiene is important for overall postpartum care, but addressing the immediate issue of constipation with a stool softener takes precedence in this scenario.
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A patient with a history of chronic kidney disease presents with weakness, anorexia, and confusion. Laboratory tests reveal severe anemia, low reticulocyte count, elevated serum creatinine, and decreased erythropoietin levels. Which of the following conditions is most likely to cause these findings?
- A. Anemia of chronic disease
- B. Hemolytic uremic syndrome (HUS)
- C. Autoimmune hemolytic anemia (AIHA)
- D. Renal failure-associated anemia
Correct Answer: D
Rationale: The clinical presentation of a patient with chronic kidney disease (CKD) presenting with weakness, anorexia, confusion, severe anemia, low reticulocyte count, elevated serum creatinine, and decreased erythropoietin levels is most consistent with renal failure-associated anemia. In CKD, the kidneys are unable to produce adequate amounts of erythropoietin, a hormone responsible for stimulating red blood cell production in the bone marrow. The decreased erythropoietin levels lead to a state of anemia, characterized by low hemoglobin levels and subsequent symptoms of fatigue and weakness. The anemia in renal failure is typically normocytic and normochromic. Additionally, the elevated serum creatinine in this patient is a hallmark of kidney dysfunction.
A nurse is caring for a patient with limited mobility and is planning interventions to prevent pressure injuries. What action by the nurse demonstrates evidence-based practice in pressure injury prevention?
- A. Applying moisturizing lotion to the patient's skin daily
- B. Turning and repositioning the patient every 2 hours
- C. Placing the patient on an alternating pressure mattress
- D. Massaging the bony prominences to improve circulation
Correct Answer: C
Rationale: Placing the patient on an alternating pressure mattress demonstrates evidence-based practice in pressure injury prevention. Alternating pressure mattresses are designed to change pressure points by alternating pressure across different parts of the body, reducing the risk of pressure injuries. Regularly turning and repositioning the patient (Choice B) is also important in preventing pressure injuries, but an alternating pressure mattress provides additional support and prevention measures. Applying moisturizing lotion (Choice A) and massaging bony prominences (Choice D) may be beneficial for skin care, but they are not proven strategies for pressure injury prevention.
A nurse is preparing to perform a continuous bladder irrigation (CBI) procedure for a patient following urological surgery. What action should the nurse prioritize to prevent complications during CBI?
- A. Adjusting the irrigation flow rate based on the patient's urine output
- B. Changing the irrigation solution every 24 hours to maintain sterility
- C. Using tap water for irrigation to prevent electrolyte imbalances
- D. Limiting the duration of CBI to minimize the risk of bladder distention
Correct Answer: A
Rationale: The nurse should prioritize adjusting the irrigation flow rate based on the patient's urine output to prevent complications during continuous bladder irrigation (CBI). Proper adjustment of the irrigation flow rate helps maintain adequate bladder drainage while preventing bladder distention, clot formation, and potential irrigation fluid overload. Monitoring the patient's urine output and adjusting the flow rate accordingly ensures optimal functioning of the CBI system and enhances patient safety. This proactive approach minimizes the risk of complications and promotes effective postoperative care following urological surgery.
Based on her knowledge on otitis media, Nurse Selma recalls that children are predisposed to AOM due to the following rish factors, EXCEPT ______.
- A. absence of breastfeeding
- B. swimming
- C. exposure to cigarette smoke
- D. poor hygiene
Correct Answer: A
Rationale: Breastfeeding is actually a protective factor against acute otitis media (AOM) in children due to the antibodies and nutrients present in breast milk that help strengthen the immune system and the Eustachian tube function. Swimming, exposure to cigarette smoke, and poor hygiene are all risk factors for AOM. Swimming can introduce water into the ears, which can lead to infections. Exposure to cigarette smoke can irritate the mucous membranes in the respiratory tract and increase the risk of infections. Poor hygiene can lead to the spread of bacteria that can cause AOM.
Which of the following statements indicate an effective communication technique used by the unit manager to her staff?
- A. "We need to improve our nursing services otherwise top management will take over,
- B. "Lets limit requesting supplies and equipment, our budget for our promotion might be affected."
- C. "There are a lot of redundant positions in our unit, there is a need to retrench some staff."
- D. "We need to discuss strategic approaches to facilitate delivery of nursing services with less expense on our consumers."
Correct Answer: D
Rationale: Option D demonstrates an effective communication technique used by the unit manager because it focuses on discussing strategic approaches to improve the delivery of nursing services while also considering cost effectiveness for the consumers. By emphasizing the need for strategic planning and efficient service delivery, the manager is promoting a proactive and solution-oriented approach rather than simply stating potential negative outcomes or making abrupt decisions like in the other options. This approach fosters more open communication, collaboration, and problem-solving within the team, ultimately leading to better outcomes and team morale.