A postpartum client presents with sudden chest pain, dyspnea, and tachycardia. Which nursing action should be prioritized?

Correct Answer: D

Rationale: Sudden chest pain, dyspnea, and tachycardia in a postpartum client can be indicative of serious conditions such as pulmonary embolism or myocardial infarction. These conditions are emergencies that require immediate medical attention. Notifying the healthcare provider immediately is the priority to ensure prompt evaluation and intervention to address the potential life-threatening situation. While other nursing interventions such as elevating the head of the bed, providing supplemental oxygen therapy, and administering analgesics may be necessary, they should be done after notifying the healthcare provider to ensure appropriate management of the underlying cause.

Correct Answer: C

Rationale: It is essential for nurses to record vital signs and notes on a patient as soon as they obtain them. This allows for accurate and timely documentation of crucial information related to the patient's health status. By recording the information promptly, nurses can ensure that they do not forget important details and can provide effective care based on accurate data. Waiting for lunch break or after completing other tasks can lead to delays in documentation, which may compromise patient care and safety. Therefore, the ideal and proper time for recording vital signs and notes is immediately after obtaining them.

Correct Answer: B

Rationale: Obtaining informed consent is primarily the responsibility of the physician. Informed consent is a crucial ethical and legal concept in healthcare that requires the healthcare provider, usually the physician, to ensure that the patient understands the proposed treatment, including the risks, benefits, alternatives, and potential outcomes, before agreeing to proceed with the treatment. While other healthcare professionals, such as nurses, nurse managers, anesthesiologists, and midwives, may also play a role in the informed consent process by providing information and clarifying details, it is ultimately the physician who must obtain the patient's informed consent before any treatment or procedure is performed.

Correct Answer: B

Rationale: Medical records are typically required to be retained for a certain period of time as mandated by legal and regulatory requirements. The retention period for medical records is generally between 5 to 10 years, depending on the jurisdiction and specific regulations governing healthcare facilities. Keeping medical records for this duration ensures that they are available for reference, audits, legal purposes, and continuity of care for patients. Storing medical records for an adequate length of time also helps in ensuring continuity of care and tracking patients' medical history over time, which is crucial for quality healthcare delivery. Therefore, storing charts in the Medical Records or storage room for at least 5-10 years aligns with standard practices in healthcare compliance and patient care.

Correct Answer: C

Rationale: The submandibular gland is located inferior and posterior to the mandible. It produces a mixed type of saliva, which is primarily serous (enzyme-rich) but also contains some mucous components. This gland plays a significant role in digestion, as its serous saliva contains enzymes such as amylase that help break down carbohydrates in the mouth before they reach the stomach.

Correct Answer: D

Rationale: It is important for the nurse to explore Ella's feelings further when she expresses thoughts of wishing to be dead and struggling with not having someone around. These statements indicate that Ella may be experiencing emotional distress or depression, which require immediate attention. By exploring Ella's feelings, the nurse can assess the severity of her emotional state, provide appropriate support, and potentially prevent any harm or self-harm. It is crucial to address and validate her emotions, as well as to initiate necessary interventions to ensure her safety and well-being.

Correct Answer: C

Rationale: When assessing and managing distress in a patient with advanced dementia who is no longer able to communicate verbally, the palliative nurse should consider exploring non-verbal cues and behaviors to identify the underlying causes of distress. Since the patient cannot communicate through words, it is essential to pay close attention to their non-verbal cues such as facial expressions, body language, and changes in behavior. Distress in dementia patients can be caused by a variety of factors including physical discomfort, unmet needs, environmental stressors, emotional distress, or even medication side effects. By carefully observing and interpreting non-verbal cues, the nurse can gain insight into what might be causing the patient's distress and tailor interventions accordingly. Simply focusing on physical comfort measures may not address the root cause of the distress, and administering sedative medications without understanding the underlying cause is not considered best practice in palliative care for dementia patients.

Correct Answer: C

Rationale: A pituitary adenoma is a type of benign tumor that arises from the pituitary gland, which is located at the base of the brain. When a pituitary adenoma grows large enough, it can compress surrounding structures, including the optic chiasm – the point at which the optic nerves cross over in the brain. Compression of the optic chiasm can lead to symptoms such as vision problems (e.g., visual disturbances), headaches, and nausea/vomiting, which are consistent with the presentation described in the question. Meningiomas, glioblastoma multiforme, and medulloblastomas are less likely to compress the optic chiasm and present with different characteristic symptoms based on their locations and growth patterns.

Correct Answer: C

Rationale: The most appropriate intervention for the palliative nurse to prioritize in this situation is to offer emotional support and validate the patient's feelings about body image changes. End-stage renal disease can lead to significant physical changes such as edema and weight gain, which can impact a patient's body image and self-esteem. By providing emotional support and validating the patient's feelings, the nurse can help address the patient's distress and concerns, improving their overall psychological well-being. While providing education on dietary modifications (choice B) and prescribing diuretic medications (choice D) may be important aspects of managing fluid retention and edema, addressing the patient's emotional distress and body image concerns should be the initial priority in a palliative care setting. Encouraging the patient to accept their body changes (choice A) may overlook the emotional impact these changes have on the patient, making choice C the most appropriate intervention.