A patient in the ICU develops catheter-related bloodstream infection (CRBSI) associated with a central venous catheter. What intervention should the healthcare team prioritize to manage the patient's infection?

Correct Answer: A

Rationale: The primary intervention that should be prioritized for managing a catheter-related bloodstream infection (CRBSI) associated with a central venous catheter is to remove the central venous catheter. CRBSI is a serious complication that can lead to severe infections and sepsis. The removal of the catheter is crucial to eliminate the source of the infection and prevent further dissemination of the pathogens into the bloodstream. Once the catheter is removed, the healthcare team can consider other interventions such as administering targeted antibiotics based on culture results, performing blood cultures to identify the causative organism, and implementing sterile dressing changes and catheter care protocols. However, immediate removal of the catheter takes precedence in managing CRBSI to prevent worsening of the infection and improve patient outcomes.

Correct Answer: B

Rationale: Vitamin K is essential for the production of several clotting factors in the liver, including factors II, VII, IX, and X. In a patient with chronic liver disease, impaired liver function can lead to decreased synthesis of these clotting factors. As a result, there is an underlying deficiency of these clotting factors, leading to prolonged PT (prothrombin time) and aPTT (activated partial thromboplastin time). The mixing studies showing correction with normal plasma further support the diagnosis of a factor deficiency rather than an inhibitor, which helps in ruling out conditions like DIC or hemophilia.

Correct Answer: D

Rationale: Nurse Rey can be liable for committing malpractice. Malpractice refers to professional negligence or failure to provide the standard of care expected in a particular medical situation. In this scenario, Nurse Rey is not qualified or authorized to perform circumcisions, as it falls outside of the scope of practice for a nurse. By participating in performing circumcisions without the necessary qualifications and training, Nurse Rey is potentially putting patients at risk and not providing the appropriate standard of care expected from a healthcare professional. This could be considered as malpractice, for which Nurse Rey may be held liable.

Correct Answer: A

Rationale: Pressure injuries on the heels are a concern as they can develop quickly and lead to serious complications, especially in surgical patients who are immobile for extended periods. Applying pressure-relieving devices, such as heel protectors or foam dressings, can help alleviate the pressure on the affected areas and prevent further damage. These devices are designed to distribute pressure evenly and reduce the risk of pressure injuries. It is important for the nurse to address the issue promptly to prevent additional harm to the patient's skin integrity.

Correct Answer: B

Rationale: One of the signs and symptoms of Benign Prostatic Hyperplasia (BPH) is not pain on urination. BPH is a non-cancerous enlargement of the prostate gland which can cause urinary symptoms such as frequency of urination, dribbling of urine, hesitancy in starting urination, weak urine flow, feeling of incomplete bladder emptying, and increased urination at night (nocturia). Pain on urination is not typically associated with BPH, and it may suggest other urinary tract issues such as a urinary tract infection or a different medical condition.

Correct Answer: B

Rationale: The responsibility of obtaining informed consent typically falls on the physician or the healthcare provider who is performing the procedure or treatment. Informed consent is a process where the healthcare provider explains the procedure, its risks, benefits, possible alternatives, and potential outcomes to the patient or their legal representative. The patient must have a comprehensive understanding of these aspects before agreeing to the treatment. While nurses, nurse managers, anesthesiologists, midwives, and other healthcare professionals may assist in the consent process by providing information or clarifications, the ultimate responsibility lies with the physician. This is because the physician is usually the one with the expertise and knowledge about the specific procedure or treatment being performed.

Correct Answer: A

Rationale: An occiput posterior fetal position, where the baby's head is facing the mother's abdomen rather than her back, can lead to prolonged and severe back pain during labor. This position can cause irregular contractions and difficulty in descending through the birth canal, resulting in abnormal labor progress. The back pain experienced in this case is often intense due to the pressure exerted on the mother's lower back and may also be associated with intense back labor. It is essential for the nurse to recognize this potential issue and assist in maneuvers or positions to help the baby rotate to a more optimal position for delivery.

Correct Answer: C

Rationale: The symptoms described, including progressive weakness, muscle atrophy, fasciculations, dysphagia, and dysarthria primarily involving the upper and lower extremities, are classic features of amyotrophic lateral sclerosis (ALS), also known as Lou Gehrig's disease. ALS is a progressive neurodegenerative disorder that affects the motor neurons in the brain and spinal cord, leading to muscle weakness and atrophy. As the disease progresses, patients may develop difficulty swallowing (dysphagia) and speaking (dysarthria). In contrast, Parkinson's disease primarily involves movement-related symptoms such as tremors, muscle stiffness, and slow movements. Guillain-Barré syndrome (GBS) is an acute inflammatory demyelinating polyneuropathy that typically presents with ascending weakness and sensory abnormalities, often preceded by an infection. Myasthenia gravis is characterized by muscle weakness exacerbated by

Correct Answer: A

Rationale: Providing education on techniques to improve latch and milk transfer should be prioritized to support successful breastfeeding in this situation. Newborns who are macrosomic (large for gestational age) may have difficulties latching due to their size and may require additional support to effectively breastfeed. By educating the postpartum client on proper latch techniques and milk transfer, the nurse can help optimize the breastfeeding experience for both the mother and baby. This intervention focuses on addressing the specific concerns related to the infant's size and aims to promote successful breastfeeding despite potential challenges. As such, recommending supplemental formula feedings, encouraging the client to avoid breastfeeding, or immediately referring to a lactation consultant may not directly address the immediate need for support in improving breastfeeding in this situation.