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What is the appropriate sequence of steps in the assessment of a conscious trauma patient?
- A. Airway, breathing, circulation, disability, exposure (ABCDE).
- B. Circulation, airway, breathing, disability, exposure (CABDE).
- C. Breathing, airway, circulation, disability, exposure (BACDE).
- D. Exposure, disability, circulation, airway, breathing (EDCAB).
Correct Answer: A
Rationale: The appropriate sequence of steps in the assessment of a conscious trauma patient is the ABCDE approach, which stands for Airway, Breathing, Circulation, Disability, and Exposure.
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A woman in active labor demonstrates persistent occiput posterior fetal position, contributing to prolonged labor and severe back pain. What nursing intervention should be prioritized to facilitate fetal rotation and optimize labor progress?
- A. Assisting the mother into a hands-and-knees position
- B. Administering intravenous opioids for pain relief
- C. Preparing for immediate instrumental delivery
- D. Initiating continuous electronic fetal monitoring
Correct Answer: A
Rationale: Placing the mother in a hands-and-knees position can help facilitate fetal rotation from occiput posterior to the desired occiput anterior position. This position utilizes gravity to assist in the repositioning of the baby, ultimately helping to alleviate back pain and promoting more efficient labor progress. It allows the baby's head to descend properly into the pelvis, potentially reducing the risk of a prolonged labor or the need for instrumental delivery. Additionally, being in this position can help the mother feel more comfortable and empowered during labor. Overall, assisting the mother into a hands-and-knees position is a non-invasive, low-risk intervention that can have a positive impact on both the mother and baby's well-being during labor.
Radical abdominal hysterectomy involves the removal of which structure(s)?
- A. uterus and vagina
- B. uterus and fallopian tubes
- C. uterus and ovaries
- D. uterus, ovaries,ligaments and fallopian tubes
Correct Answer: D
Rationale: Radical abdominal hysterectomy involves the removal of the uterus, ovaries, ligaments (including round ligaments and uterosacral ligaments), and fallopian tubes. This extensive procedure is typically done for cases of invasive gynecologic cancers, most commonly cervical or ovarian cancer. The goal of radical hysterectomy is to remove as much of the cancerous tissue as possible to improve the chances of successful treatment and reduce the risk of cancer recurrence.
During surgery, the nurse notices that the patient's temperature is dropping below the normal range. What should the nurse do?
- A. Increase the ambient room temperature in the operating room
- B. Administer a warming blanket or forced-air warming device
- C. Document the temperature trend in the patient's chart
- D. Continue monitoring the patient's temperature closely
Correct Answer: B
Rationale: In a situation where a patient's temperature is dropping below the normal range during surgery, the nurse should prioritize actively warming the patient to prevent hypothermia. Administering a warming blanket or using a forced-air warming device are effective methods to increase the patient's body temperature and prevent any complications that may arise from hypothermia. Increasing the ambient room temperature can help, but it may not be as direct or effective as applying targeted heat sources to the patient. Documenting the temperature trend in the patient's chart is important for record-keeping purposes, but immediate action to address the dropping temperature is necessary. Continuously monitoring the patient's temperature closely is important, but action should be taken promptly to prevent further decline.
A woman in active labor is experiencing intense pain and requests non-pharmacological pain relief measures. What intervention should the nurse prioritize?
- A. Providing continuous labor support
- B. Administering intravenous opioids
- C. Performing epidural analgesia
- D. Initiating nitrous oxide inhalation
Correct Answer: A
Rationale: When a woman in active labor is experiencing intense pain and requests non-pharmacological pain relief measures, the nurse should prioritize providing continuous labor support. Continuous labor support, also known as a doula or labor companion, has been shown to be effective in reducing the perception of pain and improving labor outcomes. The presence of a supportive person can provide physical, emotional, and informational support, helping the woman cope with the pain and navigate through the labor process. This intervention can enhance the woman's overall experience of labor and improve maternal and neonatal outcomes without the need for pharmacological interventions. Administering opioids, performing epidural analgesia, or initiating nitrous oxide inhalation are pharmacological pain relief measures and may not align with the woman's preference for non-pharmacological options.
A nurse is preparing to perform an intracranial pressure (ICP) monitoring procedure for a patient with traumatic brain injury. What action should the nurse prioritize to ensure procedural accuracy?
- A. Ensuring proper zeroing and calibration of the ICP monitoring system
- B. Positioning the patient in a high-Fowler's position during the procedure
- C. Administering prophylactic antibiotics to prevent infection
- D. Placing the ICP monitor in the subarachnoid space via lumbar puncture
Correct Answer: A
Rationale: The nurse should prioritize ensuring proper zeroing and calibration of the ICP monitoring system to ensure procedural accuracy and reliability of the measurements obtained. Proper zeroing involves setting the transducer at the level of the patient's external auditory meatus (ear), which serves as a reference point for accurate ICP readings. Calibration is necessary to establish accurate pressure measurements. Incorrect zeroing or calibration can lead to inaccurate ICP readings, which can impact clinical decision-making for patients with traumatic brain injury. Positioning the patient in a high-Fowler's position, administering prophylactic antibiotics, or placing the ICP monitor in the subarachnoid space via lumbar puncture are not directly related to ensuring the accuracy of the ICP monitoring procedure.