A patient in the ICU develops acute kidney injury (AKI) secondary to hypovolemic shock. What intervention should the healthcare team prioritize to manage the patient's renal function?

Correct Answer: A

Rationale: In a patient with acute kidney injury (AKI) secondary to hypovolemic shock, the priority intervention to manage the patient's renal function is to administer intravenous fluids to restore circulating volume. Hypovolemic shock leads to decreased blood flow to the kidneys, resulting in hypoperfusion and ischemic damage to the renal tubules. Prompt correction of hypovolemia with intravenous fluids helps improve renal perfusion and function by increasing blood flow to the kidneys. Adequate fluid resuscitation can potentially prevent further kidney damage and support kidney function recovery. It is crucial to address the underlying cause of AKI (hypovolemia in this case) to prevent complications and improve patient outcomes. Initiating renal replacement therapy or recommending nephrotoxic medications would not be the initial interventions for managing AKI in this scenario.

Correct Answer: B

Rationale: The healthcare team should prioritize implementing environmental modifications to promote orientation in a patient with delirium. Delirium is a state of acute confusion and agitation that can be triggered by various factors such as medications, infections, or metabolic disturbances. Environmental modifications involve creating a calm, quiet, and well-lit environment for the patient. Promoting proper orientation through the use of clocks, calendars, and familiar objects can help reduce confusion and improve the patient's understanding of their surroundings. These interventions are non-pharmacological and aim to address the underlying causes of delirium while minimizing the need for additional medications that may have potential side effects. Antipsychotic medications and benzodiazepines should be used judiciously and under close supervision due to the risk of adverse effects in older adults and critically ill patients. Referring the patient to a psychiatrist may be considered if the delirium is complex or if there are underlying psychiatric issues contributing to the presentation.

Correct Answer: C

Rationale: During a transurethral resection of the prostate (TURP), fluid irrigation is commonly used to distend the bladder and flush out tissue debris. However, it is important to prioritize preventing fluid overload in the patient. Limiting the duration of irrigation fluid instillation is a crucial action to prevent excessive fluid absorption and subsequent fluid overload. Prolonged irrigation may lead to an increased risk of fluid overload and electrolyte imbalances, which can result in serious complications such as hyponatremia and fluid volume excess. Monitoring the patient's serum electrolyte levels can be important, but limiting the duration of irrigation is a more immediate and proactive measure to prevent fluid overload. Administering diuretic medications before the procedure may not be appropriate without assessing the patient's specific fluid status and needs. Adjusting the irrigation fluid temperature, while important for hemostasis, does not directly

Correct Answer: B

Rationale: The patient can tell all information to the nurse once the feeling of security is established in the nurse-patient relationship. Open communication and sharing of information are essential components of nursing care. Patients are more likely to disclose personal information, concerns, and feelings when they trust their nurse and feel secure in the relationship. Building trust and creating a safe and supportive environment are crucial for effective therapeutic communication and holistic patient care. It is important for the nurse to establish a trusting relationship with the patient to encourage open communication and provide patient-centered care.

Correct Answer: A

Rationale: Respondent superior is a legal doctrine that holds an employer (such as a nurse) responsible for the actions of their employees (such as a barangay health worker) performed within the scope of their employment. In the scenario provided, the nurse delegated tasks to the barangay health worker, making the health worker an agent of the nurse. By closely monitoring the delegated work, the nurse is fulfilling her legal responsibility under the principle of respondent superior to ensure that the health worker performs their duties properly and in accordance with professional standards.

Correct Answer: C

Rationale: Accurate documentation, whether done manually or electronically by health care professionals, is a critical component of information management in a health care delivery system. Information management involves the collection, storage, processing, and sharing of data to support decision-making and ensure quality care for patients. Properly documented records enable health care providers to have access to relevant information about a patient's medical history, treatment plans, and progress. This helps in delivering effective and coordinated care, reducing medical errors, and improving overall patient outcomes. Moreover, well-kept records are essential for legal and regulatory compliance, billing, quality assessment, and research purposes. Therefore, accurate documentation plays a key role in information management within the healthcare setting.

Correct Answer: B

Rationale: The recommended screening test for cervical cancer prevention in women aged 21 to 65 years is cytology, also known as a Pap smear. The Pap smear is a test that looks for changes in the cells of the cervix that could indicate the presence of cervical cancer or pre-cancerous conditions. This test is recommended every 3 years for women aged 21-29 years, and every 3-5 years for women aged 30-65 years, depending on the screening method used. HPV testing alone or co-testing with both cytology and HPV testing may be used in certain situations, but for most women in this age group, cytology (Pap smear) alone is the recommended screening test.

Correct Answer: B

Rationale: Option B, "Maintaining professional boundaries helps protect both patients and nurses," indicates an understanding of the importance of professional boundaries in nursing practice. Professional boundaries define the limits of the nurse-patient relationship and help ensure that interactions are safe, therapeutic, and based on the patient's best interest. By maintaining these boundaries, nurses can uphold ethical standards, prevent harm, and maintain trust with patients. It also helps prevent issues such as transference, countertransference, and breaches of confidentiality. Overall, understanding and respecting professional boundaries are essential for promoting the well-being of both patients and healthcare providers.

Correct Answer: C

Rationale: In ALS (Amyotrophic Lateral Sclerosis), communication difficulties may occur as the disease progresses and affects the muscles responsible for speech. It is crucial to initiate early measures to assist the patient in communicating effectively. Using pre-signals before the loss of speech can be helpful in maintaining communication with the patient. These pre-signals can include gestures, writing tools, communication boards, or technology-assisted communication devices. By introducing and practicing these pre-signals early on, the patient can adapt and utilize alternative communication methods before the loss of speech becomes more challenging. This proactive approach can significantly improve the patient's ability to communicate and maintain a sense of connection with others.