A patient receiving palliative care for end-stage liver disease experiences severe pruritus. What intervention should the palliative nurse prioritize to address the patient's symptoms?

Correct Answer: D

Rationale: In end-stage liver disease, pruritus (itching) can be a distressing symptom caused by the accumulation of bile salts in the skin due to impaired liver function. Cholestyramine and other bile acid sequestrants are the primary treatment for managing pruritus in these patients. These medications bind to the bile salts in the intestine, preventing their reabsorption and reducing the itching symptoms. Antihistamines may not be as effective for this type of pruritus since it is not histamine-mediated. Topical corticosteroids are generally not recommended for long-term use in liver disease due to the risk of systemic absorption and adverse effects. Avoiding hot showers or baths may provide some temporary relief but is not a definitive treatment. Therefore, prioritizing the prescription of cholestyramine or bile acid sequestrants would be the most appropriate intervention to address the severe pruritus in a patient with end-stage liver disease

Correct Answer: B

Rationale: The correct action for the nurse to ensure proper insertion technique during a urinary catheterization is to use aseptic technique and sterile equipment. This is crucial in preventing infections and ensuring patient safety. Aseptic technique involves maintaining cleanliness and preventing the introduction of harmful microorganisms during invasive procedures like catheterization. Using sterile equipment helps minimize the risk of introducing bacteria into the urinary tract, which could lead to a urinary tract infection (UTI). Therefore, it is essential that the nurse follows strict infection control protocols and uses sterile equipment to maintain patient safety and well-being during the catheterization procedure.

Correct Answer: D

Rationale: Nurse Noli should not advise patients to eat more saturated fats. Saturated fats are known to increase cholesterol levels and can lead to heart disease and other health issues. It is recommended to limit the intake of saturated fats in the diet. Therefore, advising patients to eat more saturated fats goes against the goal of promoting heart-healthy habits. Instead, Nurse Noli should focus on encouraging patients to cut down on salt intake, consume more fruits and vegetables, and eat regular meals to maintain a balanced and healthy diet.

Correct Answer: B

Rationale: Mood swings are recognized as a typical part of a normal pregnancy due to the hormonal changes that occur. Pregnant individuals may experience a wide range of emotions, from joy and elation to frustration and irritability. These fluctuations in mood are considered normal and not necessarily indicative of a more serious issue. It is essential for pregnant women to receive support and understanding during this time as they navigate the emotional ups and downs of pregnancy. Feelings being easily hurt by remarks (A) and narcissism (D) are not typically accepted as part of a normal pregnancy and may require further attention or support. While finding a situation amusing or charming (C) can be a positive experience, it is not specifically indicative of a normal emotional reaction during pregnancy.

Correct Answer: D

Rationale: After childbirth, the uterus undergoes involution, which is the process of returning to its pre-pregnant size and location. Initially, the fundus is firm and located at or just below the level of the umbilicus immediately after delivery. Over the next 24 hours, the fundus should gradually decrease in height as involution progresses. By the day after delivery, the nurse would expect the fundal assessment to be in line with the umbilicus or slightly below it, indicating normal involution of the uterus. If the fundus remains high or deviates from this expected progression, further assessment and intervention may be needed to prevent complications such as postpartum hemorrhage.

Correct Answer: C

Rationale: When a pregnant woman is diagnosed with preeclampsia, the focus of health care shifts to the individual woman herself. Preeclampsia is a serious condition that affects the health of the pregnant woman and her unborn child. The healthcare team will prioritize the care and treatment of the woman to ensure her well-being and safety. In this scenario, the emphasis is on providing personalized and targeted care to address the needs of the individual patient, rather than a broader focus on population groups, communities, or families.

Correct Answer: A

Rationale: Nurse Nilda immediately responds to any cry from her pediatric patients to attend to her patients who cannot communicate verbally. Crying is one of the few ways infants and young children communicate their needs and discomforts. By responding promptly to their cries, Nurse Nilda can assess and address potential issues such as hunger, pain, discomfort, or other needs that the child may have. This enhances the quality of care provided and helps in comforting and soothing the child, ultimately promoting their well-being and building trust between the nurse and the patient.

Correct Answer: B

Rationale: Delegation by succession involves passing on responsibility and authority to a designated successor when the delegator is temporarily unavailable. In this scenario, the unit manager is planning to take her regular official business leave and has recommended her assistant unit manager to assume her position during her absence. This act follows the principle of succession, where the deputy or next in line is entrusted with the duties and decision-making power of the manager. This ensures a smooth transition of responsibilities and allows the operations to continue efficiently in the manager's absence.

Correct Answer: D

Rationale: When a client experiences cardiac arrest, their breathing may become insufficient, leading to inadequate elimination of carbon dioxide (CO2) from the body. With reduced CO2 elimination, the level of CO2 in the bloodstream increases, causing respiratory acidosis. This imbalance is characterized by a decrease in blood pH along with an increase in CO2 levels in the blood, resulting in an acidic environment. Respiratory acidosis is the most common imbalance seen in clients who have experienced cardiac arrest, as impaired gas exchange impacts the body's ability to maintain proper acid-base balance.