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With diagnosis of hemorrhagic stroke, the nurse teaches the caregiver that with position of the bed should be in what position?
- A. High-Fowler's
- B. Prone
- C. Fowler
- D. Flat
Correct Answer: A
Rationale: For a patient diagnosed with a hemorrhagic stroke, the caregiver should ensure that the bed is positioned in a High-Fowler's position. This position involves elevating the head of the bed between 60 to 90 degrees. Elevating the head of the bed helps to reduce intracranial pressure and promote optimal cerebral perfusion. It also assists in maintaining proper ventilation and oxygenation, which are essential for the patient's recovery. It is important to avoid positioning the patient flat or in a prone position as these may exacerbate the condition and lead to further complications.
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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.
While Mrs. Mely is on TPN she suddenly complained of slight chest pain, dyspnea and appears cyanotic. You suspect that she is experiencing what possible IMMEDIATE complication?
- A. Sepsis due to IV 1ine
- B. Hyperglycemia.
- C. Air embolism
- D. Allergic reaction to TPN
Correct Answer: C
Rationale: The symptoms described in the scenario - chest pain, dyspnea, and cyanosis - are indicative of a potential air embolism. Air embolism occurs when air enters the bloodstream, leading to blockages in blood vessels and impeding oxygen delivery to tissues. In patients receiving Total Parenteral Nutrition (TPN) through intravenous lines, the risk of air embolism exists during line manipulations, disconnections, or improper priming of the tubing. The sudden onset of symptoms like chest pain and cyanosis in a patient on TPN should raise suspicion for an air embolism, as it requires immediate intervention to prevent further complications such as cardiac arrest or stroke.
Nurses may be privy to very personal information of patients and should make every effort to make it confidential, otherwise she can be charged of ______.
- A. negligence
- B. invasion of privacy
- C. malpractice
- D. defamation
Correct Answer: B
Rationale: Nurses are bound by strict confidentiality and privacy regulations in their profession. If a nurse fails to keep a patient's personal information confidential and discloses it without authorization, they can be charged with invasion of privacy. Invasion of privacy is the wrongful intrusion into a person's private affairs without their consent, and it is a serious violation of ethical and legal standards in healthcare. Nurses must always prioritize patient confidentiality to maintain trust and uphold ethical standards in their practice.
The Right to Information does not include _________.
- A. Any change in the plan of care before the change is made
- B. Extent to which payment maybe expected from Philhealth
- C. Discount for the professional fee of the attending doctor(s)
- D. Result of the evaluation of the nature and extent of his/her disease
Correct Answer: B
Rationale: The Right to Information pertains to the patient's right to be informed about their condition, treatment plan, and to have access to relevant medical information. It does not include specific details about payment or insurance coverage, such as the extent to which payment may be expected from PhilHealth. While financial information is important for patients, it does not fall under the scope of the Right to Information in a healthcare context, which focuses more on medical information and decision-making processes.
When a patient develops a temperature of 39.8 degree centigrade after an abdominal surgery with an ongoing blood transfusion, the PACU nurse should notify the surgeon as this may indicate ______.
- A. abdominal tissue injury
- B. on going potential infection
- C. post-anesthesia drug reaction
- D. allergic reaction from blood transfusion
Correct Answer: B
Rationale: A temperature of 39.8 degrees Celsius (103.6 degrees Fahrenheit) in a patient following abdominal surgery and ongoing blood transfusion may indicate an ongoing potential infection. During surgery, the body is exposed to various microorganisms, and the stress of surgery can weaken the immune system, making the patient more susceptible to infections. Blood transfusions also carry a risk of introducing infections if not properly screened. Therefore, in this situation, an elevated temperature may be a sign that an infection is developing, and prompt notification of the surgeon is important for further evaluation and management.