After instructing a primiparous patient about episiotomy care, which of the following indicates successful teaching?

Correct Answer: A

Rationale: Wiping the episiotomy area from front to back using a blotting motion helps prevent introducing bacteria from the rectal area to the vaginal area, reducing the risk of infection. This technique also avoids causing unnecessary trauma to the healing tissues. Ensuring proper hygiene is vital to prevent complications such as infection, which is crucial for the healing process after an episiotomy.

Correct Answer: B

Rationale: Meconium-stained amniotic fluid indicates that the fetus may have passed stool in utero, which can lead to potential respiratory problems once born due to meconium aspiration. The priority action for the nurse in this situation is to prepare for immediate delivery to expedite the removal of the fetus from the contaminated environment and provide necessary interventions such as suctioning of the airway to prevent aspiration of meconium. Prompt delivery is crucial to minimize the risk of complications related to meconium aspiration syndrome. Administering oxygen, inserting a urinary catheter, and notifying the neonatal resuscitation team can be important subsequent actions, but the immediate focus should be on delivering the baby.

Correct Answer: C

Rationale: When controlling severe external bleeding from an extremity, the recommended action is to apply direct pressure with a sterile dressing. Direct pressure helps to stop the bleeding by promoting clot formation and reducing blood flow from the wound. This method is effective in most cases and should be the first response to control bleeding. Elevating the extremity above the level of the heart can be helpful in some cases, but direct pressure is the initial recommended action. Applying a tourniquet proximal to the injury site should only be done as a last resort when other methods are not successful, as it can lead to complications such as tissue damage. Removing any impaled objects can actually worsen the bleeding and should be avoided unless necessary for immediate life-saving measures.

Correct Answer: C

Rationale: In situations where a patient's family member is expressing anxiety about their loved one's condition, it is important for the nurse to provide clear and accurate information about the patient's status. By explaining the nature of the injury and reassuring the wife that her husband's condition is stable, the nurse can help alleviate her anxiety and address her concerns in a meaningful way. This intervention focuses on open communication and providing emotional support, which are crucial in helping the family member cope with the situation. It is essential to establish trust and create a supportive environment for the family member during this stressful time.

Correct Answer: C

Rationale: In emergency situations, pregnant women are typically given priority when it comes to transportation to the hospital. This is because they have unique medical needs and potential complications that require immediate attention. It is important to ensure the well-being of both the mother and the unborn child. Additionally, the health and safety of the unborn child are critical considerations in determining priority for medical treatment and transport. Therefore, the pregnant woman should be the priority for the rescue team to transport to the hospital.

Correct Answer: D

Rationale: It is important to check the medication label against the medication order before administering any medication to ensure accuracy.

Correct Answer: D

Rationale: The main goal of ethical practice in the nursing profession, including in the community setting, is centered on the welfare of clients and protecting their rights. Nurses have a professional and ethical obligation to prioritize the well-being and best interests of their patients. This includes providing high-quality care, advocating for their patients, supporting their autonomy, and upholding their rights. Ethical nursing practice is not focused on protecting the nurse or co-workers, preventing reprimand from physicians, or solely meeting the satisfaction of patients' families. Ensuring the welfare and rights of clients is the fundamental ethical principle that guides nursing practice.

Correct Answer: D

Rationale: A nurse should have a sense of accountability for his actions. This means taking responsibility for one's decisions and behaviors while working in the healthcare setting. Accountability ensures that the nurse is aware of the consequences of his actions and is willing to accept ownership and follow through on commitments. It is a critical aspect of nursing practice as it helps maintain professional standards, promote patient safety, and uphold trust and integrity within the profession. Nurses are entrusted with the well-being of their patients, so being accountable for their actions is essential in providing high-quality care and maintaining ethical standards.

Correct Answer: B

Rationale: The patient's symptoms of unilateral nasal congestion, facial pain, and purulent nasal discharge with tenderness over the affected sinus are suggestive of acute sinusitis. Acute sinusitis is typically caused by a viral or bacterial infection leading to inflammation and swelling of the sinus mucosa, resulting in the characteristic symptoms described. The tenderness over the affected sinus indicates inflammation in that area. Allergic rhinitis typically presents with bilateral nasal congestion, clear nasal discharge, and itching, rather than facial pain and purulent discharge. Nasal polyps are associated with chronic conditions and usually lead to more gradual onset of symptoms. A deviated nasal septum may contribute to chronic sinus issues but typically does not present with acute symptoms of infection like purulent discharge and facial pain.