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A postpartum client presents with persistent, severe headache, photophobia, and altered mental status. Which nursing action is most appropriate?
- A. Encouraging the client to rest in a dark, quiet room
- B. Providing acetaminophen for headache relief
- C. Notifying the healthcare provider immediately
- D. Offering a massage to relieve muscle tension
Correct Answer: C
Rationale: The most appropriate nursing action when a postpartum client presents with persistent, severe headache, photophobia, and altered mental status is to notify the healthcare provider immediately. These symptoms could be indicative of serious conditions such as postpartum preeclampsia or postpartum eclampsia, both of which require prompt medical evaluation and intervention. Delaying medical attention in such cases can lead to severe complications for the mother. Therefore, it is crucial to prioritize the client's safety and well-being by quickly involving the healthcare provider for further assessment and management.
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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.
She was asked by the nurse supervisor about her concern and what are the considered ideal fetal positions for a healthy delivery?
- A. Right occipitoposterior with no flexion
- B. Right occipitoposterior with full flexion
- C. Left transverse anterior in moderate flexion
- D. Left Sacroanterior with full flexion
Correct Answer: C
Rationale: The considered ideal fetal position for a healthy delivery is left transverse anterior with moderate flexion. This position allows for an easier descent through the birth canal and reduces the chances of complications during delivery. This position is optimal for a smoother and safer delivery process for both the mother and the baby.
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.
A patient with a severe viral infection exhibits reduced levels of circulating lymphocytes. Which of the following mechanisms is most likely responsible for this observation?
- A. Apoptosis of infected lymphocytes
- B. Clonal expansion of memory T cells
- C. T cell anergy
- D. Upregulation of adhesion molecules on lymphocytes
Correct Answer: A
Rationale: A patient with a severe viral infection exhibiting reduced levels of circulating lymphocytes is likely due to the apoptosis of infected lymphocytes. When a virus enters the body, it can infect and replicate within lymphocytes, subsequently triggering the immune system to induce apoptosis in infected cells to prevent further spread of the virus. This process is part of the body's defense mechanism to control the viral infection. As a result, the circulating lymphocyte levels may decrease as infected lymphocytes are targeted for apoptosis. This phenomenon helps to limit viral replication and spread within the body, thereby aiding in the immune response to eliminate the virus.
After tracheostomy procedure, the nurse documents important observation made during the procedure such us _________.
- A. Response of the patient's after procedure
- B. Vital signs of the patient's during the procedure
- C. Amount, color and consistency of sputum and appearance of the incision
- D. Behavior of the patient during the procedure
Correct Answer: C
Rationale: It is essential for the nurse to document important observations made during a tracheostomy procedure, and this includes the amount, color, and consistency of sputum as well as the appearance of the incision. Monitoring these factors helps assess the patient's respiratory status, risk of infection, and wound healing progress. Ensuring detailed documentation in this area allows for timely intervention if there are any concerning changes observed post-procedure. Observations such as the response of the patient, vital signs during the procedure, and patient behavior are also important but may be documented separately from the specific details related to sputum, incision appearance, and wound care.