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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 provides care on a bone marrow transplant unit and is preparing a female patient for a hematopoietic stem cell transplantation (HSCT) the following day. What information should the nurse emphasize to the patients family and friends?
- A. Your family should likely gather at the bedside in case theres a negative outcome.
- B. Make sure she doesnt eat any food in the 24 hours before the procedure.
- C. Wear a hospital gown when you go into the patients room.
- D. Do not visit if youve had a recent infection.
Correct Answer: D
Rationale: The correct answer is D: Do not visit if you've had a recent infection. This is crucial to prevent the transmission of infections to the patient, who will have a compromised immune system post-HSCT. Family and friends with recent infections can pose a serious risk to the patient's health.
Choice A is incorrect because it instills fear and negativity in the family without providing any tangible benefits.
Choice B is incorrect as fasting is not typically required before a HSCT and can be harmful to the patient's nutritional status.
Choice C is incorrect as wearing a hospital gown is generally not necessary for visitors, unless specified by the healthcare team for infection control purposes.
A nurse is assessing a 28-year-old man with HIV who has been admitted with pneumonia. In assessing the patient, which of the following observations takes immediate priority?
- A. Oral temperature of 100F
- B. Tachypnea and restlessness
- C. Frequent loose stools
- D. Weight loss of 1 pound since yesterday
Correct Answer: B
Rationale: The correct answer is B: Tachypnea and restlessness. This observation takes immediate priority as it indicates potential respiratory distress, a common complication of pneumonia in HIV patients. Tachypnea can be a sign of hypoxia, while restlessness may indicate increased work of breathing. Prompt intervention is crucial to prevent respiratory failure.
Choice A: Oral temperature of 100F is not an immediate priority as it is within normal range and may not directly impact the patient's immediate condition.
Choice C: Frequent loose stools may suggest gastrointestinal issues but are not as urgent as respiratory distress in this scenario.
Choice D: Weight loss of 1 pound since yesterday, while relevant in monitoring the patient's condition, does not require immediate intervention compared to respiratory distress.
A nurse wants to reduce data entry errors onthe computer system. Which action should the nurse take?
- A. Use the same password all the time.
- B. Share password with only one other staff member.
- C. Print out and review computer nursing notes at home.
- D. Chart on the computer immediately after care is provided.
Correct Answer: D
Rationale: The correct answer is D because charting on the computer immediately after care is provided reduces the chances of forgetting important details and ensures accuracy. It also allows for real-time documentation, improving patient care. Choice A is incorrect as using the same password all the time poses a security risk. Choice B is incorrect as sharing passwords compromises confidentiality. Choice C is incorrect as printing out and reviewing notes at home does not address data entry errors on the computer system.
What should the nurse recognize as evidence that the patient is recovering from preeclampsia?
- A. 1+ protein in urine
- B. 2+ pitting edema in lower extremities
- C. Urine output >100 mL/hour
- D. Deep tendon reflexes +2
Correct Answer: C
Rationale: Step 1: Increased urine output indicates improved kidney function, a key indicator of recovery from preeclampsia.
Step 2: Adequate urine output helps regulate blood pressure and reduce swelling.
Step 3: Consistent urine output >100 mL/hour signifies the kidneys are functioning properly.
Step 4: Therefore, C is the correct answer as it directly reflects recovery progress from preeclampsia.
Summary: A, B, and D are incorrect as they do not directly correlate with kidney function or recovery from preeclampsia.
A nurse is teaching preventative measures for otitis externa to a group of older adults. What action should the nurse encourage?
- A. Rinsing the ears with normal saline after swimming
- B. Avoiding loud environmental noises
- C. Instilling antibiotic ointments on a regular basis
- D. Avoiding the use of cotton swabs
Correct Answer: A
Rationale: The correct answer is A: Rinsing the ears with normal saline after swimming. This is because rinsing with normal saline helps to remove excess moisture and debris, preventing bacterial growth that can lead to otitis externa. Avoiding loud noises (B) is important for overall ear health but does not specifically prevent otitis externa. Instilling antibiotic ointments regularly (C) is not recommended as it can disrupt the ear's natural flora. Avoiding cotton swabs (D) is important to prevent injury but does not directly prevent otitis externa.