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When a patient develops a temperature of 39.8 degree centigrade after an abdominal surgery with an ongoing blood transfusion, the PACU nurse should notify the surgeon as this may indicate ______.
- A. abdominal tissue injury
- B. on going potential infection
- C. post-anesthesia drug reaction
- D. allergic reaction from blood transfusion
Correct Answer: B
Rationale: A temperature of 39.8 degrees Celsius (103.6 degrees Fahrenheit) in a patient following abdominal surgery and ongoing blood transfusion may indicate an ongoing potential infection. During surgery, the body is exposed to various microorganisms, and the stress of surgery can weaken the immune system, making the patient more susceptible to infections. Blood transfusions also carry a risk of introducing infections if not properly screened. Therefore, in this situation, an elevated temperature may be a sign that an infection is developing, and prompt notification of the surgeon is important for further evaluation and management.
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A nurse is preparing to perform a colposcopy procedure for a patient with abnormal cervical cytology results. What action should the nurse prioritize to enhance patient comfort during colposcopy?
- A. Administering intravenous sedation to the patient before the procedure
- B. Explaining the procedure steps and providing emotional support to the patient
- C. Applying a topical anesthetic cream to the cervix before colposcopy
- D. Allowing the patient to have a support person present during the procedure
Correct Answer: B
Rationale: The best action the nurse should prioritize to enhance patient comfort during a colposcopy procedure is to explain the procedure steps and provide emotional support to the patient. Colposcopy is a procedure that involves examining the cervix, vagina, and vulva closely. Patients may feel anxious or uncomfortable during the procedure due to the sensitive nature of the area being examined and the potential concerns related to abnormal cervical cytology results. By explaining the procedure steps in detail before starting and providing emotional support, the nurse can help alleviate the patient's fears and anxieties, thereby enhancing their comfort and promoting a more positive experience overall. Additionally, establishing good communication and trust with the patient can also improve their cooperation during the procedure. Administering sedation, applying a topical anesthetic cream, and allowing a support person to be present are all important factors in providing holistic care as well, but the initial priority should be on communication and emotional support.
The immunity conferred by tetanus toxoid is best described as:
- A. Lifelong passive
- B. Temporary passive
- C. Long-lasting active
- D. Lifelong active
Correct Answer: C
Rationale: Tetanus toxoid provides long-lasting active immunity. When a person is vaccinated with tetanus toxoid, their immune system is stimulated to produce antibodies against the tetanus toxin. These antibodies provide protection against tetanus infection by recognizing and neutralizing the toxin if the person is exposed to the bacteria that causes tetanus in the future. This active immune response can last for many years, providing ongoing protection against tetanus. However, booster doses are recommended every 10 years to maintain adequate levels of protection.
A patient is complaining of urinary pain after being diagnosed with a urinary tract infection the previous day. What is the nurse's best action?
- A. Administer ordered phenazopyridine hydrochloride (Pyridium).
- B. Administer ordered trimethoprim (Trimpex).
- C. Administer ordered bethanechol (Urecholine).
- D. Administer ordered acetaminophen (Tylenol) and a warm bath.
Correct Answer: B
Rationale: The nurse's best action in this situation would be to administer the ordered antibiotic trimethoprim (Trimpex). A urinary tract infection (UTI) requires antibiotic treatment to eliminate the bacterial infection causing the symptoms. Phenazopyridine hydrochloride is a urinary tract analgesic that can help relieve urinary pain but does not treat the infection itself. Bethanechol is a cholinergic medication used to treat urinary retention, not a UTI. Acetaminophen and a warm bath may help with some discomfort but do not address the underlying infection causing the urinary pain. Therefore, administering the prescribed antibiotic would be the most appropriate action to target the source of the patient's symptoms.
The young mother wanted to know about the motor development APPROPRIATE in a preschooler. Which of the following statements NOT true?
- A. "He can tie shoe lace"
- B. "He can alternate feet when climbing"
- C. "He has not developed good postures"
- D. "He can hop two or more times"
Correct Answer: B
Rationale: The statement that the preschooler can alternate feet when climbing is not true. Typically, preschoolers at this age group are still developing their coordination and may not have mastered the skill of alternating feet while climbing. It is more common for them to use one foot after the other while climbing. This skill usually requires more advanced motor development and coordination, which may come later in the preschool years.
There are five criteria in prioritizing community health problems. If Nurse Maris is estimating the proportion of the population affected by the problem, she is using what criterion in prrioritization?
- A. Social concern
- B. Nature of the problem
- C. Magnitude of the problem
- D. Modifiability of the problem
Correct Answer: C
Rationale: When Nurse Maris is estimating the proportion of the population affected by the problem, she is assessing the magnitude of the problem. The magnitude criterion involves determining the extent of the issue within the community, such as the number of individuals affected or at risk. By understanding the magnitude of a health problem, nurses can better prioritize their efforts to address the most pressing issues that affect a large portion of the population. This criterion helps in identifying which health problems have the highest impact and require immediate attention in order to improve community health outcomes.