A pregnant woman presents with sudden onset of severe abdominal pain and dark red vaginal bleeding at 28 weeks gestation. On examination, the uterus is tender, and the fundus feels firm. Which of the following conditions is the most likely cause of these symptoms?

Correct Answer: D

Rationale: The most likely cause of the sudden onset of severe abdominal pain and dark red vaginal bleeding with a tender, firm uterus at 28 weeks gestation is abruptio placentae. Abruptio placentae, also known as placental abruption, is the premature separation of the placenta from the uterine wall before delivery. This condition can be life-threatening to both the mother and the fetus, as it can lead to severe bleeding and compromise the oxygen and nutrients supply to the fetus. The presentation typically includes severe abdominal pain, dark red or maroon vaginal bleeding, uterine tenderness, and a firm uterus due to the blood accumulation behind the placenta. Prompt recognition and intervention are crucial to prevent adverse maternal and fetal outcomes.

Correct Answer: A

Rationale: Before finalizing and implementing the education plan for the staff nurse, it is important to have the plan reviewed by the nurse supervisor. The nurse supervisor is directly responsible for overseeing the staff nurses and their education and training needs. They have a good understanding of the staff nurse's current skills, areas for improvement, and training requirements. By involving the nurse supervisor in the review process, you can ensure that the education plan is aligned with the overall goals and needs of the nursing staff and the department. Additionally, the nurse supervisor can provide valuable input and insights to help tailor the education plan to meet the specific needs of the staff nurses under their supervision.

Correct Answer: D

Rationale: While all of the nursing measures listed are important considerations when managing a patient receiving oxytocin drip, the nurse would least consider informing the patient about potential complications. The reason for this is that it is the responsibility of the healthcare provider (such as the physician or advanced practice nurse) to inform the patient about potential complications of a medication or treatment. Nurses are instrumental in providing education and support to patients, but in the case of informing patients about potential complications, this task typically falls under the purview of the prescribing provider. The primary focus of the nurse in this situation would be to assess, administer, monitor, and educate the patient as appropriate, ensuring safe and effective care delivery.

Correct Answer: C

Rationale: The client is experiencing symptoms of hyperventilation, a condition that occurs when there is excessive elimination of carbon dioxide from the body. Breathing into a paper bag can help by allowing the client to rebreathe carbon dioxide, which can help restore the balance of gases in the blood and alleviate the tingling sensations in the lips and fingers. This technique is commonly used to help regulate breathing in cases of hyperventilation. Administering oxygen (choice B) may not be necessary as the issue lies with an imbalance of carbon dioxide, not a lack of oxygen. Instructing the client to blow her nose and take deep breaths (choice A) may not address the underlying problem effectively. Administering IV fluids (choice D) is not relevant to the client's symptoms of hyperventilation.

Correct Answer: B

Rationale: Monitoring oxygen saturation with pulse oximetry is essential for preventing respiratory depression in a patient prescribed an opioid analgesic. Opioid analgesics can suppress the respiratory drive, leading to respiratory depression. By constantly monitoring the patient's oxygen saturation levels with pulse oximetry, nurses can promptly detect any signs of respiratory depression and intervene early to prevent serious complications. This allows for timely adjustments in the medication dosage or administration of other supportive measures to maintain adequate oxygenation and prevent respiratory compromise. Administering naloxone prophylactically may be necessary in case of an opioid overdose but is not typically done as a preventive measure. Encouraging deep breathing exercises can help prevent respiratory complications postoperatively but may not be sufficient in the presence of opioid-induced respiratory depression. Administering bronchodilators as needed is not directly related to preventing respiratory depression caused by opioid analgesics.

Correct Answer: B

Rationale: Family support is a crucial consideration when planning the care of the elderly. The availability of family members to provide emotional support, assistance with daily activities, and decision-making can greatly impact the overall well-being of the elderly individual. Family support can help reduce feelings of isolation, ensure that the elderly person's needs are being met, and provide a sense of security and comfort. Additionally, involving family members in the care planning process can help create a collaborative and comprehensive care approach that considers the preferences and values of the elderly person. Considering the level of family support is essential for creating a care plan that meets the unique needs and circumstances of each elderly individual.

Correct Answer: D

Rationale: Hurthle cell carcinoma is a subtype of thyroid cancer that arises from the follicular cells in the thyroid gland. Patients with Hurthle cell carcinoma may present with a painful thyroid nodule, which can be associated with signs of hypothyroidism due to the disruption of thyroid hormone production by the tumor. Fine-needle aspiration biopsy revealing Hurthle cells with nuclear features suggestive of malignancy is a characteristic finding in this type of carcinoma.

Correct Answer: B

Rationale: A "full understanding" in research should be understood by the nurse researcher as explaining the study including risks and ben . When conducting research involving participants, it is crucial for nurse researchers to provide all necessary information about the study, including potential risks and benefits, in a clear and understandable manner. This ensures that participants are well-informed and can make informed decisions about their participation. By explaining the study thoroughly, nurse researchers uphold ethical principles such as informed consent and respect for participants' autonomy. It also helps in building trust between the researcher and participants, ultimately leading to more reliable and ethical research outcomes.

Correct Answer: B

Rationale: Option B, "Maintaining professional boundaries helps protect both patients and nurses," indicates an understanding of the importance of professional boundaries in nursing practice. Professional boundaries define the limits of the nurse-patient relationship and help ensure that interactions are safe, therapeutic, and based on the patient's best interest. By maintaining these boundaries, nurses can uphold ethical standards, prevent harm, and maintain trust with patients. It also helps prevent issues such as transference, countertransference, and breaches of confidentiality. Overall, understanding and respecting professional boundaries are essential for promoting the well-being of both patients and healthcare providers.