A postpartum client who experienced a third-degree perineal laceration expresses concerns about the healing process and potential complications. What nursing intervention should be prioritized to promote optimal wound healing?

Correct Answer: D

Rationale: Third-degree perineal lacerations are significant injuries that require careful monitoring for signs of infection or wound dehiscence, which are potential complications that could hinder optimal wound healing. Signs of infection may include increased redness, warmth, swelling, pain, and purulent drainage from the wound site. Dehiscence refers to the separation of the wound edges, which can be a serious complication requiring immediate attention. By closely monitoring the incision site for these signs, the nurse can promptly intervene if any complications arise, ensuring proper healing and preventing further complications. While providing perineal care, proper application of peri-pads, and encouraging sitz baths are important for comfort and cleanliness, monitoring for complications takes priority in promoting optimal wound healing in this scenario.

Correct Answer: A

Rationale: Utilizing communication and social media responsibly is an indicator that models personal and professional behavior and values. Responsible use of communication and social media demonstrates a commitment to maintaining a positive online presence, interacting respectfully with others, and upholding professional standards in digital communication. This behavior reflects integrity, accountability, and respect for oneself and others, which are essential qualities in both personal and professional settings. Additionally, demonstrating responsible behavior in the digital sphere can help build trust, enhance reputation, and foster valuable relationships with colleagues, clients, and the community.

Correct Answer: B

Rationale: Uterine atony is caused by the markedly distended uterus and intermittent uterine contractions within 2 to 3 days after birth. It is characterized by the inability of the uterus to contract after delivery, leading to excessive bleeding postpartum. This condition is a significant risk factor for postpartum hemorrhage. Treatment may involve massage of the uterus, administration of uterotonics, and in severe cases, surgical interventions such as a hysterectomy. Retained placenta refers to incomplete expulsion of the placenta after delivery. Afterpains are the discomfort felt by some women as their uterus contracts and returns to its normal size after childbirth. A boggy uterus is another term for a uterus that feels soft, lax, or lack firm tone, which can be a sign of uterine atony.

Correct Answer: C

Rationale: The symptoms described in the scenario - chest pain, dyspnea, and cyanosis - are indicative of a potential air embolism. Air embolism occurs when air enters the bloodstream, leading to blockages in blood vessels and impeding oxygen delivery to tissues. In patients receiving Total Parenteral Nutrition (TPN) through intravenous lines, the risk of air embolism exists during line manipulations, disconnections, or improper priming of the tubing. The sudden onset of symptoms like chest pain and cyanosis in a patient on TPN should raise suspicion for an air embolism, as it requires immediate intervention to prevent further complications such as cardiac arrest or stroke.

Correct Answer: B

Rationale: The primary purpose of interdisciplinary collaboration in nursing practice is to improve communication and coordination of patient care. When healthcare providers from different disciplines work together as a team, they can share their unique perspectives, knowledge, and skills to develop comprehensive care plans that address all aspects of a patient's well-being. This collaborative approach helps ensure that the patient receives holistic and coordinated care, leading to better outcomes and patient satisfaction. Effective communication and coordination among team members also help prevent errors, reduce duplication of efforts, and promote efficient use of resources. Overall, interdisciplinary collaboration is essential for delivering high-quality, patient-centered care in healthcare settings.

Correct Answer: D

Rationale: The assessment finding that is indicative of the diagnosis of hypertension is consistent evaluation of blood pressure. Hypertension is diagnosed based on repeated measurements of elevated blood pressure. Consistently high blood pressure readings, usually defined as systolic blood pressure consistently at or above 140 mmHg and diastolic blood pressure consistently at or above 90 mmHg, are a key factor in diagnosing hypertension. Family history of high blood pressure (Choice A), elevation of blood cholesterol level (Choice B), and a stressful work environment (Choice C) may be risk factors for hypertension but are not diagnostic criteria. In order to diagnose hypertension, healthcare providers rely on consistent measurement and evaluation of blood pressure over time.

Correct Answer: D

Rationale: Record keeping involves several key steps such as structuring, securing, and storing information. However, easy disposal is not a step in record keeping. In fact, it is important to carefully consider the disposal of records in a secure and responsible manner to protect sensitive information and comply with relevant regulations. Proper disposal methods should be followed to ensure that records are not accessible to unauthorized individuals and that any sensitive information is properly destroyed to prevent misuse or breaches of privacy. Therefore, easy disposal is not a recommended practice in effective record keeping.

Correct Answer: B

Rationale: The nurse should prioritize cleansing the insertion site with an alcohol-based antiseptic solution to maintain procedural asepsis during a peripherally inserted central catheter (PICC) insertion. Proper skin preparation is essential in reducing the risk of introducing pathogens into the patient's bloodstream during the insertion process. Alcohol-based antiseptic solutions are effective in reducing the number of microorganisms on the skin surface. Wearing sterile gloves and following other sterile techniques are also crucial, but preparing the insertion site with the antiseptic solution is the initial step in maintaining asepsis during the procedure.

Correct Answer: A

Rationale: The initial treatment goal for a patient like Mila is often focused on preventing infection. Infection prevention is a basic and essential step in patient care, especially for someone who may be at risk due to their medical condition or treatment plan. By preventing infection, healthcare providers can help ensure the patient's safety and promote successful outcomes for the overall treatment plan. Correcting hypoxia, metabolic acidosis, and increasing myocardial oxygen supply may be important goals as well, but preventing infection is usually prioritized as it can have serious consequences if not addressed promptly.