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What is the priority nursing intervention for the patient who has had an incomplete abortion?
- A. Methylergonovine (Methergine), 0.2 mg IM
- B. Preoperative teaching for surgery
- C. Insertion of IV line for fluid replacement
- D. Positioning of patient in left side-lying position
Correct Answer: C
Rationale: The correct answer is C because the priority nursing intervention for a patient with incomplete abortion is to ensure adequate fluid replacement to prevent hypovolemic shock due to potential blood loss. Inserting an IV line allows for immediate administration of fluids and medications if necessary. Choice A (Methylergonovine) is used to manage postpartum hemorrhage, not incomplete abortion. Choice B (Preoperative teaching) and choice D (Positioning) are important but not the priority in this situation.
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A nurse wants to present information about fluimmunizations to the older adults in the community. Which type of communication should the nurse use?
- A. Public
- B. Small group
- C. Interpersonal
- D. Intrapersonal
Correct Answer: B
Rationale: The correct answer is B: Small group. When presenting information about flu immunizations to older adults in the community, using small group communication is most effective. In small group settings, the nurse can engage with the audience, encourage discussions, answer questions, and address individual concerns. This approach allows for personalized interaction, fosters trust, and facilitates better understanding and retention of information. Public communication (choice A) may not provide the same level of individualized attention. Interpersonal communication (choice C) typically refers to one-on-one interactions, which may not reach a larger audience efficiently. Intrapersonal communication (choice D) involves self-reflection and is not suitable for disseminating information to a group.
The nurse in a pediatric ICU is caring for a child who is dying of sickle cell anemia. The childs mother has been unable to eat or sleep and can talk only about her impending loss and the guilt she feels about the childs pain and suffering. What intervention has the highest priority?
- A. Allowing the patient to express her feelings without judging her
- B. Helping the patient to understand the phases of the grieving process
- C. Reassuring the patient that the childs death is not her fault
- D. Arranging for genetic counseling to inform the patient of her chances of having another child with the disease
Correct Answer: A
Rationale: The correct answer is A: Allowing the patient to express her feelings without judging her. This intervention has the highest priority as it focuses on providing emotional support and creating a safe space for the mother to express her emotions without feeling judged. In this situation, the mother is experiencing intense guilt and grief, and allowing her to talk about her feelings can help her process her emotions and cope with the impending loss. By listening actively and without judgment, the nurse can demonstrate empathy and compassion, which are crucial in supporting the mother through this difficult time.
Summary:
B: Helping the patient to understand the phases of the grieving process may be helpful, but it is not the highest priority at this moment.
C: Reassuring the patient that the child's death is not her fault is important, but the priority is to address the mother's emotional needs first.
D: Arranging for genetic counseling is not the highest priority at this time as the immediate focus should be on providing emotional support to the mother
The nurse is discharging a patient home after mastoid surgery. What should the nurse include in discharge teaching?
- A. Try to induce a sneeze every 4 hours to equalize pressure.
- B. Be sure to exercise to reduce fatigue.
- C. Avoid sleeping in a side-lying position.
- D. Dont blow your nose for 2 to 3 weeks.
Correct Answer: D
Rationale: The correct answer is D: "Don't blow your nose for 2 to 3 weeks." After mastoid surgery, blowing the nose can increase pressure in the surgical area and disrupt healing. Here's the rationale:
1. Blowing the nose can increase pressure in the surgical area and lead to complications.
2. Avoiding blowing the nose helps prevent infection and reduces the risk of damaging the surgical site.
3. It is essential to follow this instruction to promote proper healing and reduce the chances of postoperative complications.
In summary, the other choices are incorrect because inducing a sneeze, exercising, and avoiding side-lying position do not directly relate to the specific care needs after mastoid surgery.
When planning discharge teaching with a patient who has undergone a total mastectomy with axillary dissection, the nurse knows to instruct the patient that she should report what sign or symptom to the physician immediately?
- A. Fatigue
- B. Temperature greater than 98.5F
- C. Sudden cessation of output from the drainage device
- D. Gradual decline in output from the drain
Correct Answer: C
Rationale: The correct answer is C: Sudden cessation of output from the drainage device. This is crucial because it can indicate a potential complication like a blocked drain or infection, requiring immediate medical attention to prevent further issues. Other choices like fatigue (A) are common after surgery but not urgent. Temperature elevation (B) may indicate infection but is not as critical as sudden cessation of drainage. Gradual decline in output (D) is expected as the drainage decreases over time, so it doesn't require immediate reporting.
A 42-year-old man has come to the clinic for an annual physical. The nurse notes in the patients history that his father was treated for breast cancer. What should the nurse provide to the patient before he leaves the clinic?
- A. A referral for a mammogram
- B. Instructions about breast self-examination (BSE)
- C. A referral to a surgeon
- D. A referral to a support group
Correct Answer: A
Rationale: The correct answer is A: A referral for a mammogram. Given the family history of breast cancer in the patient's father, the nurse should recommend a mammogram as a preventive measure due to increased risk. Mammograms are effective in detecting breast cancer early, especially in individuals with a family history. This can help in early diagnosis and timely intervention if needed.
B: Instructions about breast self-examination (BSE) can be helpful, but in this case, a mammogram is a more definitive screening tool for high-risk individuals.
C: A referral to a surgeon is not necessary at this point as the patient does not exhibit any symptoms of breast cancer.
D: Referral to a support group may be beneficial for emotional support, but the priority should be on proactive screening measures like a mammogram.