Nokea
Which intrapartal assessment should be avoided when caring for a patient with HELLP syndrome?
- A. Abdominal palpation
- B. Venous sample of blood
- C. Checking deep tendon reflexes
- D. Auscultation of the heart and lungs
Correct Answer: A
Rationale: The correct answer is A: Abdominal palpation. Palpating the abdomen can potentially cause rupture of the liver in patients with HELLP syndrome due to increased risk of liver hematoma. This can lead to severe bleeding and compromise the patient's condition. Checking deep tendon reflexes (C), auscultation of the heart and lungs (D), and venous sample of blood (B) are safe assessments that do not pose a risk of exacerbating the patient's condition. It is crucial to prioritize patient safety and avoid interventions that can harm the patient, making avoiding abdominal palpation the correct choice in caring for a patient with HELLP syndrome.
You may also like to solve these questions
A patient has had a total mastectomy with immediate reconstruction. The patient asks the nurse when she can take a shower. What should the nurse respond?
- A. Not until the drain is removed
- B. On the second postoperative day
- C. Now, if you wash gently with soap and water
- D. Seven days after your surgery
Correct Answer: A
Rationale: The correct answer is A: Not until the drain is removed. After a mastectomy with immediate reconstruction, there is typically a drain in place to collect fluid. Showering before the drain is removed can increase the risk of infection and disrupt the healing process. It is important to wait until the healthcare provider removes the drain to ensure proper healing and reduce the risk of complications.
Summary:
B: On the second postoperative day - Too early, the drain needs to be removed first.
C: Now, if you wash gently with soap and water - Incorrect, the drain should be removed before showering.
D: Seven days after your surgery - Incorrect, waiting for a specific number of days is not necessary, it depends on when the drain is removed.
A patient with HIV infection has begun experiencing severe diarrhea. What is the most appropriate nursing intervention to help alleviate the diarrhea?
- A. Administer antidiarrheal medications on a scheduled basis, as ordered.
- B. Encourage the patient to eat three balanced meals and a snack at bedtime.
- C. Increase the patients oral fluid intake.
- D. Encourage the patient to increase his or her activity level.
Correct Answer: C
Rationale: The correct answer is C: Increase the patient's oral fluid intake. This is because severe diarrhea can lead to dehydration, which can be dangerous for patients with HIV infection. By increasing oral fluid intake, the patient can stay hydrated and prevent further complications. Administering antidiarrheal medications on a scheduled basis (Choice A) may provide temporary relief but does not address the underlying issue of dehydration. Encouraging the patient to eat balanced meals (Choice B) and increase activity level (Choice D) may be important for overall health but do not directly address the immediate concern of dehydration caused by severe diarrhea.
A patient has returned to the floor after undergoing a transurethral resection of the prostate (TURP). The patient has a continuous bladder irrigation system in place. The patient tells you he is experiencing bladder spasms and asks what you can do to relieve his discomfort. What is the most appropriate nursing action to relieve the discomfort of the patient?
- A. Apply a cold compress to the pubic area.
- B. Notify the urologist promptly.
- C. Irrigate the catheter with 30 to 50 mL of normal saline as ordered.
- D. Administer a smooth-muscle relaxant as ordered.
Correct Answer: D
Rationale: Rationale: Administering a smooth-muscle relaxant is the most appropriate nursing action to relieve bladder spasms post-TURP. The smooth-muscle relaxant helps relax the bladder muscles, reducing spasms and discomfort. Applying a cold compress (choice A) may provide temporary relief but won't address the underlying cause. Notifying the urologist (choice B) is important but not the immediate action for relieving spasms. Irrigating the catheter with normal saline (choice C) may not effectively address the spasms. Administering a smooth-muscle relaxant is the best choice for prompt relief.
You are caring for a patient who has been diagnosed with genital herpes. When preparing a teaching plan for this patient, what general guidelines should be taught?
- A. Thorough handwashing is essential.
- B. Sun bathing assists in eradicating the virus.
- C. Lesions should be massaged with ointment.
- D. Self-infection cannot occur from touching lesions during a breakout.
Correct Answer: A
Rationale: The correct answer is A because thorough handwashing is essential in preventing the spread of genital herpes. This helps reduce the risk of transmission to other parts of the body or to other individuals. Sunbathing (B) does not eradicate the virus and can actually worsen symptoms. Massaging lesions with ointment (C) can aggravate the sores and lead to further infection. Self-infection (D) can occur from touching lesions during a breakout due to the highly contagious nature of the virus. Therefore, teaching the patient about thorough handwashing is crucial in managing and preventing the spread of genital herpes.
In teaching mothers-to-be about infant nutrition, which instruction should the nurse provide?
- A. Supplement breast milk with corn syrup.
- B. Give cow’s milk during the first year of life.
- C. Add honey to infant formulas for increased energy.
- D. Provide breast milk or formula for the first 4 to 6 months.
Correct Answer: D
Rationale: The correct answer is D because breast milk or formula is recommended for the first 4 to 6 months as it provides essential nutrients for infant growth and development. Choosing A, B, or C is incorrect as they pose health risks to infants - corn syrup is not necessary, cow's milk is not suitable for infants, and honey can cause botulism in infants under 1 year old. Breast milk or formula is the safest and most nutritionally balanced option for infants in the first few months of life.