Nokea
When the patient was informed about induction, she asks Nurse Aurora what it is all about. which of the following statement by the nurse is correct? Induction is a
- A. local anesthesia used for blocking pain during episiotomy
- B. deliberate initiation of uterine contractions that stimulates labor
- C. medication injected into the subarachnoid space and has a rapid onset of action
- D. procedure per formed by artificial rupture of the membranes
Correct Answer: B
Rationale: Induction is the deliberate initiation of uterine contractions that stimulates labor. It is usually initiated when natural labor is not progressing or is overdue. This process can involve the use of medications or other methods to help the uterus contract and initiate labor. Option B accurately describes induction, making it the correct answer in this case.
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A woman in active labor is experiencing umbilical cord prolapse. What is the priority nursing action?
- A. Elevating the mother's hips to relieve pressure on the cord
- B. Preparing for immediate cesarean section
- C. Administering intravenous fluids rapidly
- D. Applying external fetal monitoring to assess fetal heart rate
Correct Answer: B
Rationale: In the case of umbilical cord prolapse, the priority nursing action is to prepare for an immediate cesarean section. Umbilical cord prolapse is a serious obstetric emergency where the umbilical cord slips through the cervix ahead of the presenting part of the fetus. This can lead to compression of the cord, compromising fetal blood flow and oxygenation. Immediate delivery via cesarean section is necessary in order to prevent fetal hypoxia and avoid potential complications such as brain damage or death. Elevating the mother's hips or administering intravenous fluids rapidly may be interventions done in conjunction with preparing for a cesarean section, but the priority remains expedited delivery of the baby. Applying external fetal monitoring is not the most appropriate action in this emergency situation.
A patient expresses concerns about the potential side effects of a prescribed medication. What is the nurse's best approach to address these concerns?
- A. Dismiss the patient's concerns and reassure them that side effects are unlikely.
- B. Provide the patient with accurate information about potential side effects and management strategies.
- C. Ignore the patient's concerns and focus solely on administering the medication.
- D. Tell the patient that side effects are common and unavoidable.
Correct Answer: B
Rationale: The nurse's best approach to address a patient's concerns about the potential side effects of a prescribed medication is to provide the patient with accurate information about potential side effects and management strategies. It is important for the nurse to acknowledge the patient's concerns, listen attentively, and offer clear explanations to help alleviate any fears or uncertainties. Providing accurate information can empower the patient to make informed decisions about their healthcare and feel more confident in taking the prescribed medication. Dismissing or ignoring the patient's concerns can lead to mistrust and non-adherence to the treatment plan. It is essential for the nurse to prioritize open communication and patient education to ensure the patient's well-being and compliance with the prescribed medication regimen.
One morning during rounds, Nurse Myra noticed that Marlene was unduly sad. The nurse 's BEST way of communicating her concern is _______.
- A. whatever it is, you lift it up to God
- B. saying you are sad again, that is bad for your health
- C. telling Marlene to stop worrying, everything will be okay
- D. placing her hand over Marlene 's shoulder and asking why the sad face
Correct Answer: D
Rationale: Placing her hand over Marlene's shoulder and asking why the sad face is the best way for Nurse Myra to communicate her concern. This approach shows empathy and creates a safe space for Marlene to open up about her feelings. By using physical touch and showing genuine interest in Marlene's well-being, Nurse Myra can effectively address the situation and provide appropriate support or guidance as needed. Simply dismissing Marlene's feelings (option B and C) or resorting to religious advice (option A) may not effectively address the underlying cause of Marlene's sadness. It is important in situations like this to show empathy, compassion, and a willingness to listen in order to provide the best support for the individual in distress.
A nurse is preparing to assist with a transurethral resection of the prostate (TURP) procedure for a patient with benign prostatic hyperplasia (BPH). What action should the nurse prioritize to prevent fluid overload during TURP?
- A. Monitoring the patient's serum electrolyte levels during the procedure
- B. Administering diuretic medications to the patient before the procedure
- C. Limiting the duration of irrigation fluid instillation during TURP
- D. Adjusting the irrigation fluid temperature to promote hemostasis
Correct Answer: C
Rationale: During a transurethral resection of the prostate (TURP), fluid irrigation is commonly used to distend the bladder and flush out tissue debris. However, it is important to prioritize preventing fluid overload in the patient. Limiting the duration of irrigation fluid instillation is a crucial action to prevent excessive fluid absorption and subsequent fluid overload. Prolonged irrigation may lead to an increased risk of fluid overload and electrolyte imbalances, which can result in serious complications such as hyponatremia and fluid volume excess. Monitoring the patient's serum electrolyte levels can be important, but limiting the duration of irrigation is a more immediate and proactive measure to prevent fluid overload. Administering diuretic medications before the procedure may not be appropriate without assessing the patient's specific fluid status and needs. Adjusting the irrigation fluid temperature, while important for hemostasis, does not directly
A patient is prescribed an opioid analgesic for postoperative pain management. Which nursing intervention is essential for preventing respiratory depression in the patient?
- A. Administering naloxone prophylactically
- B. Monitoring oxygen saturation with pulse oximetry
- C. Encouraging deep breathing exercises
- D. Administering bronchodilators as needed
Correct Answer: B
Rationale: Monitoring oxygen saturation with pulse oximetry is essential for preventing respiratory depression in a patient prescribed an opioid analgesic. Opioid analgesics can suppress the respiratory drive, leading to respiratory depression. By constantly monitoring the patient's oxygen saturation levels with pulse oximetry, nurses can promptly detect any signs of respiratory depression and intervene early to prevent serious complications. This allows for timely adjustments in the medication dosage or administration of other supportive measures to maintain adequate oxygenation and prevent respiratory compromise. Administering naloxone prophylactically may be necessary in case of an opioid overdose but is not typically done as a preventive measure. Encouraging deep breathing exercises can help prevent respiratory complications postoperatively but may not be sufficient in the presence of opioid-induced respiratory depression. Administering bronchodilators as needed is not directly related to preventing respiratory depression caused by opioid analgesics.