Nokea
A postpartum client exhibits signs of wound infection, including erythema, warmth, and purulent drainage from a cesarean incision. Which nursing action is most appropriate?
- A. Applying a sterile dressing to the incision
- B. Irrigating the wound with saline solution
- C. Notifying the healthcare provider immediately
- D. Administering oral antibiotics as prescribed
Correct Answer: C
Rationale: When a postpartum client exhibits signs of wound infection, such as erythema, warmth, and purulent drainage from a cesarean incision, it is essential to notify the healthcare provider immediately. Wound infections can lead to serious complications if not promptly addressed. The healthcare provider will assess the infection, possibly order further diagnostic tests, and determine the appropriate course of treatment, which may include antibiotics or additional wound care measures. Applying a dressing or irrigating the wound may be part of the treatment plan prescribed by the healthcare provider, but the first step is always to seek guidance from the provider.
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A patient presents with multiple, discrete, flesh-colored papules with central umbilication on the trunk and extremities. The lesions are asymptomatic and have been present for several months. Which of the following conditions is most likely responsible for this presentation?
- A. Molluscum contagiosum
- B. Basal cell carcinoma
- C. Sebaceous hyperplasia
- D. Dermatofibroma
Correct Answer: A
Rationale: Molluscum contagiosum is a viral skin infection caused by the poxvirus. It typically presents as multiple, flesh-colored, dome-shaped papules with a central umbilication (dimple or depression in the center) on the skin. These lesions are often found on the trunk and extremities and can persist for several months. Molluscum contagiosum is commonly seen in children but can also occur in adults, especially those with weakened immune systems. The lesions are usually asymptomatic but can become inflamed or itchy in some cases. Treatment options include observation, topical therapies, cryotherapy, or curettage.
Nurse Vera informs the patient she should be screened for pre-eclmapsia during this term of pregnancy_______.
- A. first
- B. Third
- C. second
- D. Before delivery
Correct Answer: A
Rationale: Pre-eclampsia is a serious condition that can occur during pregnancy, usually after 20 weeks gestation. It is important to screen for pre-eclampsia early in the pregnancy to monitor and manage the condition effectively. Screening for pre-eclampsia typically begins in the first trimester of pregnancy to identify any risk factors and provide appropriate care for the patient. Therefore, Nurse Vera informing the patient to get screened for pre-eclampsia in the first term of pregnancy is the most appropriate time to start monitoring for this condition.
A patient with a history of Hodgkin lymphoma presents with fever, chills, and generalized malaise. Laboratory tests reveal pancytopenia, circulating Reed-Sternberg cells, and bone marrow involvement. Which of the following conditions is most likely to cause these findings?
- A. Autoimmune hemolytic anemia (AIHA)
- B. Myelodysplastic syndrome (MDS)
- C. Aplastic anemia
- D. Paraneoplastic syndrome
Correct Answer: D
Rationale: The patient is presenting with symptoms and laboratory findings consistent with a paraneoplastic syndrome related to Hodgkin lymphoma. In this case, the fever, chills, generalized malaise, pancytopenia, circulating Reed-Sternberg cells, and bone marrow involvement are all indicative of a paraneoplastic syndrome associated with Hodgkin lymphoma. Paraneoplastic syndromes are a group of disorders that are triggered by an abnormal immune response to a neoplasm, such as Hodgkin lymphoma, leading to various systemic manifestations.
While positioning the patient for surgery, the nurse notices that the patient's skin is not adequately protected from pressure injuries. What should the nurse do?
- A. Apply a pressure-relieving device to the bony prominences
- B. Document the observation in the preoperative checklist
- C. Reposition the patient to alleviate pressure on vulnerable areas
- D. Continue with the positioning as planned
Correct Answer: C
Rationale: The nurse should reposition the patient to alleviate pressure on vulnerable areas. Pressure injuries can develop when there is prolonged pressure on specific areas of the skin, leading to reduced blood flow and tissue damage. Repositioning the patient helps to relieve the pressure and prevent the development of pressure injuries. Applying a pressure-relieving device may also be helpful, but the immediate action should be to reposition the patient to address the issue. Documenting the observation is important for documentation purposes, but the priority is to take action to prevent harm to the patient. Continuing with the positioning as planned without addressing the inadequate skin protection could lead to the development of pressure injuries, which should be avoided.
Which of the following is the PRIMARY purpose of pregnancy test?
- A. It allows for counseling on nutrition.
- B. It may help in a decision to stop working at home.
- C. It enables the husband to follow the desires of the wife.
- D. It allows for early initiation of care.
Correct Answer: D
Rationale: The primary purpose of a pregnancy test is to confirm whether a woman is pregnant or not. Once pregnancy is confirmed, it is crucial for the individual to begin prenatal care as early as possible to ensure a healthy pregnancy and delivery. Early initiation of care can help monitor the health of both the mother and the developing fetus, detect any potential issues or complications early on, and provide necessary interventions or treatments. Therefore, the main objective of a pregnancy test is to enable early initiation of care for the pregnant individual.