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The priority nursing intervention when admitting a pregnant patient who has experienced a bleeding episode in late pregnancy is to
- A. monitor uterine contractions.
- B. assess fetal heart rate and maternal vital signs.
- C. place clean disposable pads to collect any drainage.
- D. perform a venipuncture for hemoglobin and hematocrit levels.
Correct Answer: B
Rationale: When admitting a pregnant patient who has experienced a bleeding episode in late pregnancy, the top priority nursing intervention is to assess fetal heart rate (FHR) and maternal vital signs. This assessment will help the nurse determine the extent of the blood loss and its impact on both the mother and the fetus. Monitoring uterine contractions is important as well, but not the priority in this situation. Placing clean disposable pads to collect any drainage is important for ongoing assessment and management but can be done after assessing the FHR and vital signs. Performing a venipuncture for hemoglobin and hematocrit levels is necessary for further evaluation but can be done after the initial assessment of FHR and vital signs. Checking the patient and fetal well-being is crucial in situations of bleeding in late pregnancy to ensure timely and appropriate intervention.
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A patient is being discharged home from the ambulatory surgical center after cataract surgery. In reviewing the discharge instructions with the patient, the nurse instructs the patient to immediately call the office if the patient experiences what?
- A. Slight morning discharge from the eye
- B. Any appearance of redness of the eye
- C. A scratchy feeling in the eye
- D. A new floater in vision
Correct Answer: B
Rationale: Redness of the eye after cataract surgery can be a sign of infection or inflammation, which are serious complications that require immediate medical attention. Redness may be accompanied by pain, swelling, or discharge, and if left untreated, it can lead to complications that may affect the surgical outcome and the patient's vision. Therefore, it is crucial for the patient to contact the office immediately if they notice any redness in their eye following cataract surgery.
A patient has a history of drug use and is screened for hepatitis B during the first trimester. Which action is most appropriate?
- A. Practice respiratory isolation.
- B. Plan for retesting during the third trimester.
- C. Discuss the recommendation to bottle feed her baby.
- D. Anticipate administering the vaccination for hepatitis B as soon as possible
Correct Answer: B
Rationale: A person who has a history of high-risk behaviors, such as drug use, should be retested for hepatitis B during the third trimester. This is because the virus can have a long incubation period before showing up in blood tests. Retesting in the third trimester ensures that if the infection was acquired after the initial screening, it will be detected in time to provide appropriate care and interventions. Retesting is important in high-risk individuals to ensure proper management and prevention of hepatitis B transmission.
A patients rapid cancer metastases have prompted a shift from active treatment to palliative care. When planning this patients care, the nurse should identify what primary aim?
- A. To prioritize emotional needs
- B. To prevent and relieve suffering
- C. To bridge between curative care and hospice care
- D. To provide care while there is still hope
Correct Answer: B
Rationale: The primary aim when transitioning a patient with rapid cancer metastases from active treatment to palliative care is to prevent and relieve suffering. Palliative care focuses on enhancing quality of life, managing symptoms, and addressing physical, emotional, and spiritual needs. By prioritizing the prevention and relief of suffering, healthcare providers can work towards improving the patient's comfort and overall well-being during this difficult time. This approach aligns with the goals of palliative care, which aim to provide holistic support and care for patients facing serious illnesses like cancer.
The nurse is caring for a patient receiving total parenteral nutrition (TPN). Which action will the nurse take?
- A. Run lipids for no longer than 24 hours.
- B. Take down a running bag of TPN after 36 hours.
- C. Clean injection port with alcohol 5 seconds before and after use.
- D. Wear a sterile mask when changing the central venous catheter dressing.
Correct Answer: D
Rationale: When caring for a patient receiving total parenteral nutrition (TPN), it is crucial to maintain strict aseptic technique to prevent infection. Wearing a sterile mask when changing the central venous catheter dressing helps to reduce the risk of introducing pathogens into the catheter site, which can lead to serious bloodstream infections. It is essential to use sterile gloves, a sterile mask, and to assess the insertion site for any signs or symptoms of infection during central venous catheter dressing changes. Additionally, to prevent infection, TPN infusion tubing should be changed every 24 hours, and no single container of TPN should be hung for longer than 24 hours, with lipids not running for longer than 12 hours.
A patient has a documented history of allergies presents to the clinic. She states that she is frustrated by her chronic nasal congestion, anosmia (inability to smell) and inability to concentrate. The nurse should identify which of the following nursing diagnoses?
- A. Deficient Knowledge of Self-Care Practices Related to Allergies
- B. Ineffective Individual Coping with Chronicity of Condition and Need for Environmental Modification
- C. Acute Confusion Related to Cognitive Effects of Allergic Rhinitis
- D. Disturbed Body Image Related to Sequelae of Allergic Rhinitis
Correct Answer: B
Rationale: The patient's frustration with chronic nasal congestion, anosmia, and inability to concentrate indicates difficulty coping with the long-term nature of her condition and the impact it has on her daily life. Additionally, her desire for relief suggests a need for environmental modifications to help manage her symptoms. This nursing diagnosis encompasses the patient's emotional response to her condition, as well as the potential need for changes in her surroundings to better support her health and well-being.