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The nurse is providing postoperative care to a patient who underwent a total abdominal hysterectomy 12 hours ago. Which of the following are appropriate nursing interventions? Select all that apply.
- A. Assist the patient with ambulation.
- B. Maintain the Foley catheter for 48 to 72 hours postoperatively.
- C. Monitor intake and output and characteristics of urin
- D. urinary tract infection
Correct Answer: A
Rationale: A. Assist the patient with ambulation: Encouraging early ambulation after surgery helps prevent complications such as blood clots, pneumonia, and pressure ulcers. It also promotes circulation and aids in the recovery process.
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A nurse is caring for a patient who has HSV and is pregnant. The patient is concerned about the fetus. What medication is safest to take?
- A. valacyclovir
- B. none
- C. acyclovir
- D. famciclovir
Correct Answer: C
Rationale: Acyclovir is the antiviral medication of choice for treating HSV (Herpes Simplex Virus) infections during pregnancy due to its known safety profile. It is classified as Category B by the FDA, indicating that there is no evidence of risk to the fetus based on animal studies. Valacyclovir and famciclovir, on the other hand, are both classified as Category B (risk cannot be ruled out) and Category C (animal studies have shown adverse effects) by the FDA, respectively. It is generally recommended to avoid taking unnecessary medications during pregnancy, but if treatment for HSV is necessary, acyclovir is considered the safest option.
The nurse is providing care to a 72-year-old female patient. While providing care, the nurse instructs the patient to slowly rise from a sitting or prone position. What is the pathophysiological reason for this instruction?
- A. The patient is at higher risk for fractures due to postmenopausal osteoporosis.
- B. The patient is at higher risk for hypotension due to decreased baroreceptor sensitivity.
- C. The patient is at higher risk for falls due to decreased muscle strength and balance
- D. The patient is at higher risk for adverse drug reactions due to decreased hepatic function
Correct Answer: B
Rationale: As people age, their baroreceptor sensitivity decreases, making them more prone to orthostatic hypotension, especially when changing positions quickly. Orthostatic hypotension is a significant concern in the elderly population as it can lead to falls and injuries. By instructing the patient to rise slowly from a sitting or prone position, the nurse is helping to prevent a rapid drop in blood pressure that can occur with sudden position changes. This precaution is particularly important in elderly patients to minimize the risk of falls and subsequent injuries.
The nurse is teaching a parenting class to new parents. Which statement should the nurse include in the teaching session about the characteristics of a healthy family?
- A. Adults agree on the majority of basic parenting principles.
- B. The parents and children have rigid assignments for all the family tasks.
- C. Young families assume total responsibility for the parenting tasks, refusing any assistance.
- D. The family is overwhelmed by the significant changes that occur as a result of childbirth. N R I G B.C M U S N T O
Correct Answer: A
Rationale: The statement the nurse should include in the teaching session about the characteristics of a healthy family is that "Adults agree on the majority of basic parenting principles." This is because in a healthy family, it is crucial for adults to be on the same page when it comes to fundamental parenting principles. Having a shared understanding of how to raise children helps create consistency in parenting approaches, which is beneficial for the overall well-being of the family unit. Collaboration and agreement on parenting principles also lead to effective communication and support between parents, fostering a positive and nurturing environment for children to grow and thrive.
What medication would the nurse include when teaching a patient about aromatase inhibitors?
- A. anastrozole (Arimidex)
- B. fulvestrant (Faslodex)
- C. tamoxifen (Novaldex)
- D. pembrolizumab (Keytruda)
Correct Answer: A
Rationale: Aromatase inhibitors, such as anastrozole (Arimidex), are commonly used in hormone receptor-positive breast cancer treatment. They work by blocking the enzyme aromatase, which helps in the production of estrogen in postmenopausal women. By reducing estrogen levels, aromatase inhibitors help in slowing down or stopping the growth of hormone receptor-positive breast cancer cells. Therefore, when teaching a patient about aromatase inhibitors, the nurse would include information about anastrozole as it is a pertinent medication in the management of hormone receptor-positive breast cancer. Fulvestrant, tamoxifen, and pembrolizumab are not aromatase inhibitors; they work through different mechanisms in breast cancer treatment.
When reviewing a new patient’s birth plan, the nurse notices that the patient will be bringing a doula to the hospital during labor. What does the nurse think that this means?
- A. The patient will have her grandmother as a support person.
- B. The patient will bring a paid, trained labor support person with her during labor.
- C. The patient will have a special video she will play during labor to assist with relaxation.
- D. The patient will have a bag that contains all the approved equipment that may help with the labor process.
Correct Answer: B
Rationale: A doula is a trained labor support person who provides physical, emotional, and informational support to the mother before, during, and after childbirth. They are not typically a family member like a grandmother (option A) and do not involve playing a special video (option C) or bringing a bag of equipment (option D). The presence of a doula can help improve birth outcomes, provide continuous support, and enhance the birthing experience for the mother.