A postpartum client presents with persistent, severe abdominal pain, tenderness, and rigidity. Which nursing action is most appropriate?

Correct Answer: C

Rationale: Persistent, severe abdominal pain, tenderness, and rigidity in a postpartum client can be indicative of serious conditions such as uterine rupture, hemorrhage, or infection, which require urgent medical attention. As a nurse, the priority action in this situation is to notify the healthcare provider immediately so that appropriate interventions can be initiated promptly to ensure the safety and well-being of the client. Administering analgesics or providing emotional support may not address the underlying cause of the symptoms and could potentially delay necessary medical treatment. Assisting the client to a comfortable position can be considered once the healthcare provider has been informed and appropriate assessments and interventions have been initiated.

Correct Answer: A

Rationale: The healthcare team should prioritize performing endoscopic hemostasis with mechanical or thermal techniques in a patient with acute gastrointestinal bleeding (GIB) requiring urgent intervention. This approach involves directly visualizing the bleeding site and applying methods such as clipping, coagulation, or band ligation to stop the bleeding. Endoscopic hemostasis is considered the gold standard for managing acute GIB as it allows for both diagnostic and therapeutic intervention in real-time, offering a targeted and effective way to control bleeding and prevent recurrent episodes. Administering proton pump inhibitors (PPIs) may help in reducing gastric acid secretion and promoting ulcer healing but is not the primary intervention for actively bleeding patients. Implementing strict bed rest may be necessary in some cases to minimize physical exertion, but it is not the primary intervention to manage acute GIB. Transfusion of fresh frozen plasma to correct coagulopathy may be necessary if

Correct Answer: A

Rationale: Checking the flow of oxygen is the priority action because it ensures that Sonny is receiving the correct amount of oxygen prescribed by the healthcare provider. Before connecting the flow meter to the oxygen outlet, turning on the oxygen, or attaching the humidifier, it is crucial to verify that the flow rate is appropriate for Sonny's condition. Monitoring and adjusting the oxygen flow will help maintain the desired oxygen saturation levels and prevent potential complications related to oxygen therapy.

Correct Answer: B

Rationale: Goiter is a condition characterized by the enlargement of the thyroid gland. The most common cause of goiter worldwide is iodine deficiency, which is required for the production of thyroid hormones. When there is insufficient iodine intake, the thyroid gland enlarges in an attempt to produce more hormones, leading to the development of goiter. While other factors can also contribute to the development of goiter, such as autoimmune diseases and certain medications, the primary cause associated with the condition is an iodine-deficient diet.

Correct Answer: D

Rationale: During the active phase of labor, a cervical dilation of 6 cm and regular contractions lasting 60 seconds each, occurring every 3 minutes indicate good progress in labor. The nurse should continue to monitor the progress closely by assessing the mother's vital signs, fetal heart rate, and the pattern of contractions. It is important to provide support and encouragement to the mother, continue with comfort measures, and be prepared to assist with the delivery when the cervix is fully dilated. This stage of labor is focused on active dilation and effacement of the cervix, and it is not yet time for the mother to push or for the nurse to administer oxytocin to augment labor.

Correct Answer: B

Rationale: Ramona Mercer's becoming a mother (BAM) theory emphasizes the dynamic transformation and evolution of a woman's persona as she transitions into motherhood. This theory acknowledges that becoming a mother is a process involving significant changes in a woman's identity, roles, and relationships. It goes beyond just the physical aspects of giving birth and delves into the psychological, emotional, and social aspects of motherhood. Therefore, statement B aligns with the core principles of Mercer's BAM theory and fosters the understanding of the process of becoming a mother.

Correct Answer: B

Rationale: Triangulation is the technique that refers to the use of multiple referents to draw conclusions about what constitutes the truth. In the context provided in the question, Nurse Tarly is organizing a study to investigate the "Caring behavior of Staff-Nurses and Satisfaction of Women with Ostomy". By gathering data from various sources such as observation, interviews, and surveys, Nurse Tarly can triangulate the information to gain a comprehensive understanding of the situation. Triangulation helps to validate findings, enhance the credibility of the study, and provide a more well-rounded view of the issue at hand.

Correct Answer: C

Rationale: The health care team will try the oral route first for Ms. C for delivering nutrition and fluid because it is the most natural and least invasive method. If the patient is able to tolerate oral intake and has adequate oral intake, it is typically the preferred route. Only if she is unable to meet her nutritional needs orally or has difficulty swallowing, then alternative routes such as nasogastric tube, gastrostomy tube, or intravenous routes may be considered. It's important to promote oral intake whenever possible to maintain the patient's quality of life and prevent complications associated with more invasive methods.

Correct Answer: B

Rationale: Nurse Chona should explain to Patient Noel that the sign of negative before the word means that he is not drinking alcohol or smoking cigarettes. This is a simple misunderstanding and clarification should help clear up any confusion. It is important to uphold patient confidentiality and respect their autonomy, rather than reprimanding the patient for looking at their own chart. It is also essential to address any discrepancies in the patient's medical record to ensure accurate information is documented for proper treatment and care.