Nokea
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.
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A patient receiving palliative care for end-stage renal disease expresses distress over changes in body image due to edema and weight gain. What intervention should the palliative nurse prioritize to address the patient's concerns?
- A. Encourage the patient to focus on accepting their body changes as part of the illness.
- B. Provide education on dietary modifications to manage fluid retention and edema.
- C. Offer emotional support and validate the patient's feelings about body image changes.
- D. Prescribe diuretic medications to reduce fluid retention and alleviate edema.
Correct Answer: C
Rationale: The most appropriate intervention for the palliative nurse to prioritize in this situation is to offer emotional support and validate the patient's feelings about body image changes. End-stage renal disease can lead to significant physical changes such as edema and weight gain, which can impact a patient's body image and self-esteem. By providing emotional support and validating the patient's feelings, the nurse can help address the patient's distress and concerns, improving their overall psychological well-being. While providing education on dietary modifications (choice B) and prescribing diuretic medications (choice D) may be important aspects of managing fluid retention and edema, addressing the patient's emotional distress and body image concerns should be the initial priority in a palliative care setting. Encouraging the patient to accept their body changes (choice A) may overlook the emotional impact these changes have on the patient, making choice C the most appropriate intervention.
Which danger sign would warrant stoppage of pills?
- A. Clear vision
- B. Decrease blood pressure
- C. Simple colds
- D. Elevation of blood pressure
Correct Answer: D
Rationale: An elevation of blood pressure would warrant stoppage of pills. High blood pressure, or hypertension, in a 4-year-old child is abnormal and needs prompt medical attention. Giving pills without monitoring or stopping them if blood pressure is elevated can lead to serious health complications. It is important to address the underlying cause of high blood pressure in a child, which may require further evaluation and management by a healthcare provider.
A postpartum client exhibits signs of deep vein thrombosis (DVT), including calf pain, swelling, and warmth. Which nursing action is most appropriate?
- A. Applying warm compresses to the affected calf
- B. Encouraging ambulation to promote circulation
- C. Notifying the healthcare provider immediately
- D. Administering anticoagulant medication as ordered
Correct Answer: C
Rationale: Deep vein thrombosis (DVT) is a serious condition that requires prompt medical intervention. The presence of calf pain, swelling, and warmth in a postpartum client are concerning signs of a potential DVT. By notifying the healthcare provider immediately, appropriate diagnostic tests, such as ultrasound imaging, can be ordered to confirm the diagnosis. Timely treatment with anticoagulant medication can then be initiated to prevent complications such as pulmonary embolism. Applying warm compresses or encouraging ambulation may exacerbate the condition by promoting clot dislodgement, making immediate notification of the healthcare provider the most appropriate nursing action in this situation.
A pregnant woman presents with severe lower abdominal pain and vaginal bleeding. On examination, she has a tender, distended abdomen. Which of the following conditions is the most likely cause of these symptoms?
- A. Ectopic pregnancy
- B. Pelvic inflammatory disease
- C. Uterine rupture
- D. Ovarian torsion
Correct Answer: C
Rationale: Uterine rupture is a serious obstetric emergency that involves a tear or rupture of the uterine wall during pregnancy. In this scenario, the pregnant woman with severe lower abdominal pain, vaginal bleeding, and a tender, distended abdomen is showing signs consistent with uterine rupture. These symptoms are typically not seen with other conditions listed.
A patient is admitted with a suspected myocardial infarction. Which cardiac biomarker is most specific for myocardial injury?
- A. Troponin
- B. Creatine kinase-MB (CK-MB)
- C. Myoglobin
- D. Brain natriuretic peptide (BNP)
Correct Answer: A
Rationale: Troponin is the most specific cardiac biomarker for myocardial injury. Troponin I and Troponin T are proteins released into the bloodstream when there is damage to the heart muscle, making them highly indicative of myocardial infarction. Troponin levels rise within a few hours of cardiac injury, peak within 24-48 hours, and can remain elevated for up to 2 weeks. Troponin is considered the gold standard biomarker for the diagnosis of acute myocardial infarction due to its high specificity and sensitivity for cardiac injury. In contrast, Creatine kinase-MB (CK-MB) and myoglobin are also used in diagnosing myocardial infarction but are less specific than troponin. Brain natriuretic peptide (BNP) is primarily used in heart failure diagnosis and management, and its levels are not specific to myocardial injury.