Nokea
Which infection control measure should Nurse Emma observe during her visit to the family.
- A. Wear mask
- B. Use face shield
- C. Use gloves
- D. Wear gown
Correct Answer: A
Rationale: Wearing a mask is an essential infection control measure to prevent the spread of respiratory illnesses, including COVID-19. By wearing a mask, Nurse Emma can reduce the risk of inhaling or exhaling respiratory droplets that may contain infectious particles, thus helping to protect herself and the family members she is visiting. Masks are particularly crucial when interacting with individuals who are sick or when physical distancing may be challenging. While using gloves, face shields, and gowns are also important infection control measures in certain situations, wearing a mask is the most relevant and effective measure during a home visit to prevent respiratory transmission of infections.
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A nurse is preparing to perform a wound irrigation procedure for a patient with a contaminated wound. What solution should the nurse use for wound irrigation?
- A. Sterile water
- B. Normal saline
- C. Hydrogen peroxide
- D. Betadine solution
Correct Answer: B
Rationale: Normal saline is the preferred solution for wound irrigation because it is isotonic and will not damage healthy tissue or delay wound healing. It helps to remove debris and pathogens from the wound, promoting a clean environment for healing. Sterile water can be used if normal saline is not available, but it may cause cellular damage if used in large volumes. Hydrogen peroxide and Betadine solution are not recommended for wound irrigation as they can be cytotoxic to the tissues and interfere with the wound healing process. It's important for the nurse to use evidence-based practice and follow recommended guidelines to promote optimal wound healing outcomes.
A woman in active labor is diagnosed with a prolapsed umbilical cord. What is the priority nursing action?
- A. Elevate the mother's hips to relieve pressure on the cord.
- B. Prepare for immediate cesarean section.
- C. Administer intravenous fluids rapidly.
- D. Perform a vaginal examination to assess cervical dilation.
Correct Answer: B
Rationale: A prolapsed umbilical cord is a medical emergency during labor because it can cause compression of the umbilical cord, leading to decreased oxygen supply to the fetus. The priority nursing action in this situation is to prepare for an immediate cesarean section. This is necessary to quickly deliver the baby and relieve pressure on the cord, preventing potential fetal distress or death. Elevating the mother's hips may help reduce pressure on the cord temporarily, but it is not the definitive treatment for a prolapsed cord. Administering intravenous fluids rapidly may be necessary, but it is not the priority intervention when the fetus is at risk due to a prolapsed cord. Performing a vaginal examination to assess cervical dilation is contraindicated in the presence of a prolapsed umbilical cord as it can further compress the cord and worsen the situation.
A patient is prescribed a benzodiazepine for the management of insomnia. Which adverse effect should the nurse monitor closely in the patient?
- A. Hypotension
- B. Hyperglycemia
- C. Daytime drowsiness
- D. Bradycardia
Correct Answer: C
Rationale: Benzodiazepines are commonly prescribed for the management of insomnia due to their sedative effects. One of the most common adverse effects of benzodiazepines is daytime drowsiness, which can impair the patient's ability to function normally during the day. Monitoring the patient closely for daytime drowsiness is important to ensure their safety and well-being, as it can affect their daily activities and increase the risk of accidents or falls. It is essential for the nurse to educate the patient on the potential for daytime drowsiness and advise them to avoid activities that require full alertness, such as driving or operating heavy machinery, until they know how the medication affects them. If the patient experiences severe or persistent daytime drowsiness, the healthcare provider may need to adjust the dosage or consider alternative treatment options.
Which element of malpractice occurs when the nurse does not act as a reasonable, prudent person would have acted in a similar circumstance?
- A. Duty
- B. Injury or damage
- C. Breach of duty
- D. Causation
Correct Answer: C
Rationale: Breach of duty is the element of malpractice that occurs when the nurse does not act as a reasonable, prudent person would have acted in a similar circumstance. This means that the nurse failed to uphold the standard of care expected in their practice. In a malpractice case, it must be proven that the nurse breached their duty of care towards the patient by not providing the expected level of skill and care that another reasonable nurse in the same situation would have provided.
A patient presents with a pruritic, eczematous rash with erythematous papules, vesicles, and excoriations on the flexural surfaces of the elbows and knees. The patient reports a personal history of asthma and hay fever. Which of the following conditions is most likely responsible for this presentation?
- A. Atopic dermatitis
- B. Contact dermatitis
- C. Seborrheic dermatitis
- D. Nummular eczema
Correct Answer: A
Rationale: Atopic dermatitis is a chronic, pruritic inflammatory skin condition that typically presents in individuals with a personal or family history of asthma and allergic rhinitis (hay fever). The characteristic presentation includes erythematous papules, vesicles, and excoriations on the flexural surfaces of the elbows and knees. This type of dermatitis is commonly seen in patients with atopy, which refers to a genetic predisposition to develop allergic diseases like asthma, hay fever, and eczema. Therefore, given the patient's personal history of asthma and hay fever along with the described rash distribution and appearance, atopic dermatitis is the most likely diagnosis.