Nokea
Upon entry of the patient to ER, the nurse must FIRST perform which nursing intervention?
- A. Inject with rabies immune globulin.
- B. Cleanse the bite with soap and running water.
- C. Inject the rabies vaccine immediately.
- D. Administer the pain reliever, as ordered.
Correct Answer: B
Rationale: The correct answer is B: Cleanse the bite with soap and running water. This is the first nursing intervention because it is crucial to prevent infection. Cleaning the bite area helps remove bacteria and debris, reducing the risk of infection. Injecting with rabies immune globulin (choice A) and rabies vaccine (choice C) should be done later as per protocol after assessing the situation. Administering pain reliever (choice D) is important but not the first priority in this scenario.
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A patient presents with severe sore throat, fever, and enlarged tonsils with exudate. Rapid antigen testing confirms group A beta-hemolytic Streptococcus (GAS) infection. Which of the following medications is the first-line treatment for this condition?
- A. Amoxicillin
- B. Azithromycin
- C. Cephalexin
- D. Clindamycin
Correct Answer: A
Rationale: The correct answer is A: Amoxicillin. Amoxicillin is the first-line treatment for GAS pharyngitis due to its effectiveness against Streptococcus bacteria. It is a penicillin-class antibiotic recommended by guidelines. Azithromycin is an alternative for patients allergic to penicillin. Cephalexin is not the first-line choice for GAS. Clindamycin is reserved for patients allergic to both penicillin and macrolides.
Nurse Merry 's application to Canada has finally been approved and she was advised to depart in three months But, she is also enrolled in the graduate school and ambivalent to go because of this engagement plus the fact that her mother has just been discharged from the hospital. Which of the following actions is BEST?
- A. Tell family that the. money spent in graduate school can be easily earned in Canada
- B. Inform the agency that she could go anytime as they wish.
- C. Tell the recruiter to give her more time to settle her personal affairs.
- D. Share to friends this is her escape from her sad life with her family.
Correct Answer: C
Rationale: The correct answer is C. Nurse Merry should tell the recruiter to give her more time to settle her personal affairs before departing to Canada. This is the best action because it shows responsibility and consideration for her current commitments and family situation. By requesting more time, she can prioritize her mother's recovery and complete her graduate studies, demonstrating good decision-making skills and care for her loved ones.
Option A is incorrect because it dismisses the importance of family and personal obligations. Option B is incorrect as it shows a lack of planning and responsibility. Option D is incorrect as it suggests running away from problems instead of addressing them responsibly.
A postpartum client presents with severe abdominal pain, nausea, and vomiting. Which nursing action is most appropriate?
- A. Administering antiemetic medication as ordered
- B. Encouraging the client to drink clear fluids
- C. Assessing for signs of peritonitis or surgical abdomen
- D. Providing a heating pad to alleviate abdominal discomfort
Correct Answer: C
Rationale: In a postpartum client who presents with severe abdominal pain, nausea, and vomiting, it is crucial to assess for signs of peritonitis or surgical abdomen. These signs may include rebound tenderness, guarding, rigidity, and fever. Peritonitis is a serious condition that may require immediate surgical intervention. Administering antiemetic medication, encouraging clear fluids, or providing a heating pad may not address the underlying cause of the symptoms and delay appropriate treatment. Assessing for signs of peritonitis or surgical abdomen is crucial for prompt identification and management of the client's condition.
In as much as Almira complained of vaginal spotting and abdominal cramps, which among the following will the nurse anticipate as the MOST likely diagnosis of the physician after a vaginal examination?
- A. Eclampsia
- B. Threatened abortion
- C. Placenta previa
- D. Abruptio placenta
Correct Answer: B
Rationale: The correct answer is B: Threatened abortion. Vaginal spotting and abdominal cramps are common symptoms of a threatened abortion, which occurs when there is a risk of miscarriage but the pregnancy remains viable. This diagnosis is likely after a vaginal examination to assess the cervix and presence of fetal heartbeat.
A: Eclampsia is characterized by seizures in pregnancy due to high blood pressure, not typically presenting with vaginal spotting and cramps.
C: Placenta previa involves the placenta covering the cervix, leading to painless vaginal bleeding, not associated with cramps.
D: Abruptio placenta is premature separation of the placenta from the uterus, manifesting as painful bleeding, not typically with vaginal spotting and cramps.
A woman in active labor demonstrates signs of prolonged second stage, characterized by ineffective pushing efforts and slow fetal descent. What maternal condition should the nurse assess for that may contribute to this abnormal labor pattern?
- A. Maternal fatigue
- B. Pelvic floor dysfunction
- C. Fetal macrosomia
- D. Maternal hypotension
Correct Answer: B
Rationale: When a woman in active labor exhibits signs of prolonged second stage, such as ineffective pushing efforts and slow fetal descent, one of the maternal conditions that should be considered is pelvic floor dysfunction. The pelvic floor muscles play a crucial role in supporting the uterus, bladder, and rectum. If these muscles are weak or dysfunctional, it can lead to difficulty in pushing effectively and impede the descent of the fetus through the birth canal. This can result in prolonged labor and increase the risk of complications for both the mother and the baby. Therefore, assessing for pelvic floor dysfunction is important in addressing the abnormal labor pattern and providing appropriate interventions to support the progress of labor.