Nokea
A postpartum client presents with persistent, severe perineal pain despite analgesic medication. On assessment, the nurse observes ecchymosis and swelling of the perineum. Which nursing action is most appropriate?
- A. Applying ice packs to the perineum for pain relief
- B. Encouraging the client to sit on a donut cushion
- C. Notifying the healthcare provider immediately
- D. Administering additional analgesic medication
Correct Answer: C
Rationale: The presence of persistent, severe perineal pain along with ecchymosis and swelling of the perineum can indicate a complication such as a hematoma. A hematoma is a collection of blood that can occur in the perineal area postpartum, usually as a result of trauma during delivery. It is essential to notify the healthcare provider immediately to assess the situation, provide appropriate treatment, and prevent further complications. Applying ice packs or administering additional analgesic medication may not address the underlying issue of a possible hematoma, so prompt medical evaluation is crucial in this situation.
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A nurse administer as extra dose of vaccine to a child and the patient developed adverse reaction and died. She can be sued for _____.
- A. Negligence
- B. Tort
- C. Malpractice
- D. Battery
Correct Answer: C
Rationale: In this scenario, the nurse can be sued for malpractice. Malpractice refers to the failure of a professional, in this case, a nurse, to provide the standard of care that a reasonably prudent nurse would have provided in similar circumstances, resulting in harm to the patient. Administering an extra dose of vaccine leading to an adverse reaction and death of the patient is considered a form of medical malpractice as it involves a breach in the standard of care. Generally, malpractice cases involve errors or negligence in the performance of professional duties, which result in harm to the patient.
During the normal postpartum course, when would the nurse expect to note the fundal assessment that will be in line with the umbilicus?
- A. Immediately after the delivery
- B. 4 days after the delivery
- C. When the client's bladder is full
- D. The day after the delivery
Correct Answer: D
Rationale: After childbirth, the uterus undergoes involution, which is the process of returning to its pre-pregnant size and location. Initially, the fundus is firm and located at or just below the level of the umbilicus immediately after delivery. Over the next 24 hours, the fundus should gradually decrease in height as involution progresses. By the day after delivery, the nurse would expect the fundal assessment to be in line with the umbilicus or slightly below it, indicating normal involution of the uterus. If the fundus remains high or deviates from this expected progression, further assessment and intervention may be needed to prevent complications such as postpartum hemorrhage.
Nurse Roberto is aware that a client who has experienced cardiac arrest is MOST at risk for which of the following imbalances?
- A. Metabolic alkalosis
- B. Metabolic acidosis
- C. Respiratory alkalosis
- D. Respiratory acidosis
Correct Answer: D
Rationale: When a client experiences cardiac arrest, their breathing may become insufficient, leading to inadequate elimination of carbon dioxide (CO2) from the body. With reduced CO2 elimination, the level of CO2 in the bloodstream increases, causing respiratory acidosis. This imbalance is characterized by a decrease in blood pH along with an increase in CO2 levels in the blood, resulting in an acidic environment. Respiratory acidosis is the most common imbalance seen in clients who have experienced cardiac arrest, as impaired gas exchange impacts the body's ability to maintain proper acid-base balance.
A postpartum client who is breastfeeding expresses concerns about breast engorgement and discomfort. What nursing intervention should be prioritized to alleviate symptoms?
- A. Encouraging frequent breastfeeding or pumping sessions
- B. Applying cold packs to the breasts between feedings
- C. Recommending the use of a supportive bra or breast binder
- D. Administering oral analgesics for pain relief
Correct Answer: A
Rationale: The most appropriate nursing intervention to alleviate breast engorgement and discomfort in a breastfeeding client is to encourage frequent breastfeeding or pumping sessions. Engorgement occurs when the breasts become overly full of milk, causing them to become swollen, firm, and painful. By ensuring that the baby breastfeeds frequently, the client can effectively empty the breasts, which helps to relieve engorgement and discomfort. Encouraging the client to breastfeed on demand and ensuring proper latching can help prevent further engorgement issues. Pumping can also be useful if the baby is unable to feed directly from the breast or to relieve engorgement between feedings. This intervention addresses the root cause of the problem and promotes the client's comfort and breastfeeding success. Applying cold packs, using a supportive bra or breast binder, and administering oral analgesics may provide some relief for discomfort but do not address the underlying issue of engorgement.
A patient presents with chest pain, dyspnea, and signs of hypotension. An electrocardiogram (ECG) shows ST- segment elevation in the inferior leads. Which cardiovascular disorder is most likely responsible for these symptoms?
- A. Stable angina
- B. Unstable angina
- C. Acute myocardial infarction
- D. Aortic dissection
Correct Answer: C
Rationale: Chest pain, dyspnea, hypotension, and ST-segment elevation on an ECG in the inferior leads are classic signs of an acute myocardial infarction (MI). An acute MI occurs when there is a sudden blockage of blood flow to a part of the heart muscle, leading to tissue damage. This causes symptoms such as chest pain due to ischemia, dyspnea due to heart failure, and hypotension due to poor cardiac output. The ST-segment elevation seen on the ECG is indicative of significant myocardial injury. Prompt diagnosis and management are crucial in acute MI to prevent further complications and to minimize damage to the heart muscle. It is important to differentiate an acute MI from stable or unstable angina or other cardiovascular disorders, as the management and prognosis vary significantly.