Nokea
Which of the following actions is appropriate for managing a conscious patient with a foreign object lodged in the eye?
- A. Attempting to remove the object with tweezers.
- B. Rinsing the eye with sterile saline solution.
- C. Applying pressure to the eyelid to dislodge the object.
- D. Placing a bandage over the affected eye.
Correct Answer: B
Rationale: When managing a conscious patient with a foreign object lodged in the eye, the appropriate action is to rinse the eye with sterile saline solution. This helps to flush out the foreign object and reduce the risk of further injury or infection. Attempting to remove the object with tweezers or applying pressure to the eyelid can potentially cause more harm to the eye. Placing a bandage over the affected eye is not beneficial in this situation as it does not address the presence of the foreign object. Rinsing the eye with sterile saline solution is the safest and most effective initial step to take in managing a foreign object lodged in the eye.
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A nurse is preparing to assist with a peripherally inserted central catheter (PICC) insertion for a patient. What action should the nurse prioritize to maintain procedural asepsis?
- A. Wearing sterile gloves and a surgical mask during the procedure
- B. Cleansing the insertion site with alcohol-based antiseptic solution
- C. Using a sterile drape to cover the patient during the procedure
- D. Avoiding unnecessary movement or talking during the procedure
Correct Answer: B
Rationale: The nurse should prioritize cleansing the insertion site with an alcohol-based antiseptic solution to maintain procedural asepsis during a peripherally inserted central catheter (PICC) insertion. Proper skin preparation is essential in reducing the risk of introducing pathogens into the patient's bloodstream during the insertion process. Alcohol-based antiseptic solutions are effective in reducing the number of microorganisms on the skin surface. Wearing sterile gloves and following other sterile techniques are also crucial, but preparing the insertion site with the antiseptic solution is the initial step in maintaining asepsis during the procedure.
A postpartum client who experienced a third-degree perineal laceration expresses concerns about the healing process and potential complications. What nursing intervention should be prioritized to promote optimal wound healing?
- A. Providing perineal care using peri-bottles with warm water
- B. Instructing the client on proper peri-pad application to the incision
- C. Encouraging the use of sitz baths for pain relief and wound cleansing
- D. Monitoring the incision site for signs of infection or dehiscence
Correct Answer: D
Rationale: Third-degree perineal lacerations are significant injuries that require careful monitoring for signs of infection or wound dehiscence, which are potential complications that could hinder optimal wound healing. Signs of infection may include increased redness, warmth, swelling, pain, and purulent drainage from the wound site. Dehiscence refers to the separation of the wound edges, which can be a serious complication requiring immediate attention. By closely monitoring the incision site for these signs, the nurse can promptly intervene if any complications arise, ensuring proper healing and preventing further complications. While providing perineal care, proper application of peri-pads, and encouraging sitz baths are important for comfort and cleanliness, monitoring for complications takes priority in promoting optimal wound healing in this scenario.
Which of these measures will help stabilize mentally the parents of Nurse Lailanie?
- A. Establish a regular routine
- B. Repaint or buy a new furniture
- C. Move to small apartment
- D. Correct bad behaviors gently
Correct Answer: A
Rationale: Establishing a regular routine can be very helpful in stabilizing the mental state of parents. Consistency and structure in day-to-day activities can provide a sense of predictability and control, which can help reduce anxiety and stress. By having a routine, the parents can feel more organized, efficient, and better equipped to manage their responsibilities and emotions. Additionally, a regular routine can promote better sleep patterns, healthier habits, and overall well-being. This measure is practical, achievable, and can have positive effects on the mental stability of Nurse Lailanie's parents.
Patient Presley asks the nurse why such a diagnostic procedure is required. What is the MOST APPR0PRIATE answer can the nurse give?
- A. Urinary tract infections are strongly associated with the occurrence of preterm labor
- B. Reduced sensation to urinate usually occur during preterm labor
- C. Preterm 1abor treatment usually causes women a bladder infection because of restricted fluid intake
- D. Catheterized urine is usually ordered for any woman admitted to the labor and delivery unit
Correct Answer: A
Rationale: Urinary tract infections are strongly associated with the occurrence of preterm labor. It is important to screen for and address any urinary tract infections during pregnancy to reduce the risk of complications like preterm labor. Diagnostic procedures, such as obtaining a urine sample for testing, help healthcare providers identify and treat any infections promptly to promote a healthy pregnancy. Therefore, the nurse can explain to Patient Presley that the diagnostic procedure is necessary to detect and address any potential urinary tract infections that could impact her pregnancy.
A patient receiving palliative care for end-stage chronic obstructive pulmonary disease (COPD) expresses a desire to discuss advance care planning. What action should the palliative nurse take?
- A. Dismiss the patient's request and focus on symptom management.
- B. Initiate a conversation about advance directives and future care preferences.
- C. Encourage the patient to postpone discussions about advance care planning.
- D. Refer the patient to a social worker for assistance with advance care planning.
Correct Answer: B
Rationale: When a patient receiving palliative care for end-stage COPD expresses a desire to discuss advance care planning, the palliative nurse should initiate a conversation about advance directives and future care preferences. Advance care planning involves discussing and documenting a patient's preferences regarding future medical care, particularly in situations where the patient may no longer be able to make decisions. This discussion helps ensure that the patient's wishes are respected and followed in the event they are unable to communicate their preferences. By engaging in advance care planning discussions, the nurse can help the patient feel empowered, supported, and in control of their medical care decisions. It also allows healthcare providers to align care with the patient's values and goals, ultimately improving quality of life and ensuring dignity at the end of life.