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When a woman in early pregnancy is leaving the clinic, she blushes and asks the nurse if it is true that sex during pregnancy is bad for the baby. What is the best response for the nurse to give?
- A. The baby is protected by the sac. Sex is perfectly alright.
- B. It is unlikely to harm the baby. What you do with your personal life is your concern.
- C. Intercourse during pregnancy is usually alright, but you need to ask the doctor if it is acceptable for you.
- D. In a normal pregnancy, intercourse will not harm the baby. However, many women experience a change in desire. How are you feeling?
Correct Answer: D
Rationale: Choice D is the best response as it reassures the patient that intercourse in a normal pregnancy will not harm the baby. It also shows empathy by acknowledging that many women experience changes in sexual desire during pregnancy. This response validates the patient's concerns and opens up a dialogue about her feelings. Choice A is incorrect as it lacks information about changes in sexual desire and oversimplifies the situation. Choice B is dismissive of the patient's concerns and does not provide adequate information. Choice C is not the best response as it suggests asking the doctor without offering immediate reassurance or addressing the patient's worries.
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A client is post-operative day two from a total hip arthroplasty. The nurse notices the surgical wound is red and warm to the touch. What is the most appropriate action?
- A. Apply an ice pack to the incision site.
- B. Monitor the client's temperature.
- C. Document the findings and continue to monitor.
- D. Notify the healthcare provider.
Correct Answer: D
Rationale: The correct action when a nurse notices redness and warmth at the surgical wound post total hip arthroplasty is to notify the healthcare provider. These signs may indicate an infection, and prompt evaluation by the healthcare provider is crucial to initiate appropriate treatment. Applying an ice pack (Choice A) may not address the underlying issue of a potential infection. Monitoring the client's temperature (Choice B) is important but not the priority when signs of infection are present. Documenting the findings and continuing to monitor (Choice C) is necessary but should be accompanied by notifying the healthcare provider for further assessment and intervention.
A client is admitted to the postoperative surgical unit with two test tubes after a left lobectomy. The nurse observed that the chambers are set at the prescribed suction of 20 cm water pressure, and tidying occurs with respirations and bubbling. What action should the nurse implement?
- A. Clamp the chest tube to see if the bubbling activity stops
- B. Notify the registered nurse of the observed bubbling
- C. Maintain system integrity to promote lung reexpansion
- D. Apply an occlusive dressing to the chest
Correct Answer: C
Rationale: Maintaining system integrity is essential to promote lung reexpansion in postoperative patients with chest tubes. Clamping the chest tube abruptly can lead to tension pneumothorax, a life-threatening condition. The bubbling observed is a normal sign indicating that the system is functioning correctly, as it allows the drainage of air or fluid from the pleural space. Notifying the registered nurse may be necessary if there are significant concerns or changes observed, but the immediate action should be to ensure system integrity and lung reexpansion.
The nurse enters a male client's room to administer routine morning medications, and the client is on the phone. Which action is best for the nurse to take?
- A. Ask another nurse to return with the medication when the client has hung up the phone
- B. Wait for the client to excuse himself from the telephone conversation, and observe the client taking the medication
- C. Return the medication to the client's drawer on the cart and document that the client refused the dose
- D. Leave the medication with the client and let him take it when he finishes the conversation
Correct Answer: B
Rationale: The best action for the nurse to take in this situation is to wait for the client to excuse himself from the telephone conversation and then observe the client taking the medication. This approach ensures that the client takes the medication as prescribed, promoting compliance and safety. Choice A is not ideal as it involves unnecessary delegation and may lead to confusion. Choice C is incorrect because assuming refusal without direct communication can compromise patient care. Choice D is not recommended as leaving the medication with the client unsupervised may result in non-compliance or potential errors.
A nurse who receives a patient in the operative suite prior to the actual surgery is in charge of the patient's care. Which of the following is NOT a task related to the nurse's intraoperative care?
- A. Go over the surgical procedure with the patient before he or she is anesthetized
- B. Strictly adhere to asepsis during all intraoperative procedures
- C. Provide emotional support to the patient and their family
- D. Monitor the patient's physical status
Correct Answer: A
Rationale: The correct answer is A. Going over the surgical procedure with the patient is typically done preoperatively, not intraoperatively. Intraoperative tasks of a nurse involve strictly adhering to asepsis during procedures, monitoring the patient's physical status, and providing emotional support to the patient and their family during the surgery. Choices B, C, and D are all tasks that are directly related to the nurse's responsibilities during the intraoperative phase of care.
The nurse is caring for a client with pericarditis. Which of the following nursing interventions will promote comfort for the client?
- A. Auscultating the client's heart sounds
- B. Provide the client with a diversionary activity
- C. Encourage deep breathing
- D. Maintain a patent intravenous access
Correct Answer: B
Rationale: Providing a diversionary activity is the most appropriate nursing intervention to promote comfort for a client with pericarditis. This intervention helps to distract the patient and reduce discomfort by focusing their attention elsewhere. Auscultating heart sounds, while important for monitoring the condition, does not directly address the client's comfort. Encouraging deep breathing can be beneficial for some conditions but may not be specifically aimed at promoting comfort in pericarditis. Maintaining a patent intravenous access is essential for treatment access and management of the condition, but it does not directly promote comfort for the client.