and tumor necrosis factor-alpha (TNF-α) during the acute phase response?

Correct Answer: A

Rationale: Macrophages are the primary cells responsible for producing tumor necrosis factor-alpha (TNF-α) during the acute phase response. TNF-α is a pro-inflammatory cytokine that plays a critical role in initiating and propagating the inflammatory response. Macrophages secrete TNF-α in response to infection, injury, or other inflammatory stimuli, contributing to the recruitment of immune cells and the activation of additional inflammatory pathways. In the context of the acute phase response, macrophages are key mediators of the immune response and play a crucial role in host defense mechanisms.

Correct Answer: A

Rationale: The primary intervention that should be prioritized for managing a catheter-related bloodstream infection (CRBSI) associated with a central venous catheter is to remove the central venous catheter. CRBSI is a serious complication that can lead to severe infections and sepsis. The removal of the catheter is crucial to eliminate the source of the infection and prevent further dissemination of the pathogens into the bloodstream. Once the catheter is removed, the healthcare team can consider other interventions such as administering targeted antibiotics based on culture results, performing blood cultures to identify the causative organism, and implementing sterile dressing changes and catheter care protocols. However, immediate removal of the catheter takes precedence in managing CRBSI to prevent worsening of the infection and improve patient outcomes.

Correct Answer: A

Rationale: Providing education on techniques to improve latch and milk transfer should be prioritized to support successful breastfeeding in this situation. Newborns who are macrosomic (large for gestational age) may have difficulties latching due to their size and may require additional support to effectively breastfeed. By educating the postpartum client on proper latch techniques and milk transfer, the nurse can help optimize the breastfeeding experience for both the mother and baby. This intervention focuses on addressing the specific concerns related to the infant's size and aims to promote successful breastfeeding despite potential challenges. As such, recommending supplemental formula feedings, encouraging the client to avoid breastfeeding, or immediately referring to a lactation consultant may not directly address the immediate need for support in improving breastfeeding in this situation.

Correct Answer: A

Rationale: Battery refers to the intentional touching of another person without consent, resulting in harm or offense. In this scenario, the nurse inserted the urinary catheter into the client's urethra without the client's consent, leading to an injury. This action constitutes battery as the nurse carried out a medical procedure without the client's permission, resulting in harm to the client. The client can sue the nurse for battery in this situation.

Correct Answer: D

Rationale: Transcription errors are typically associated with issues such as illegible handwriting, misinterpretation of directions, and the use of unapproved abbreviations. However, the wrong route of medication administration is not specifically related to transcription errors but rather falls under the category of medication administration errors. Administering medication via the wrong route can lead to serious consequences for the patient and is a separate issue from the act of transcribing doctor's orders.

Correct Answer: D

Rationale: Nurse Rey can be liable for committing malpractice. Malpractice refers to professional negligence or failure to provide the standard of care expected in a particular medical situation. In this scenario, Nurse Rey is not qualified or authorized to perform circumcisions, as it falls outside of the scope of practice for a nurse. By participating in performing circumcisions without the necessary qualifications and training, Nurse Rey is potentially putting patients at risk and not providing the appropriate standard of care expected from a healthcare professional. This could be considered as malpractice, for which Nurse Rey may be held liable.

Correct Answer: A

Rationale: Nurse Nilda immediately responds to any cry from her pediatric patients to attend to her patients who cannot communicate verbally. Crying is one of the few ways infants and young children communicate their needs and discomforts. By responding promptly to their cries, Nurse Nilda can assess and address potential issues such as hunger, pain, discomfort, or other needs that the child may have. This enhances the quality of care provided and helps in comforting and soothing the child, ultimately promoting their well-being and building trust between the nurse and the patient.

Correct Answer: D

Rationale: The most appropriate diagnostic examination to confirm the incidence of hypertension among residents is blood pressure (BP) monitoring. Hypertension is defined by elevated blood pressure readings consistently measured over time. Monitoring of blood pressure is essential for diagnosing hypertension and determining the severity of the condition. Chest x-ray, ultrasound, and electrocardiogram are not specific tests for diagnosing hypertension. While these tests may be useful in assessing potential complications or causes of hypertension, they do not directly confirm the presence of high blood pressure. Regular BP monitoring with the use of a sphygmomanometer or automated blood pressure device is crucial in diagnosing and managing hypertension.

Correct Answer: A

Rationale: Placing the mother in a hands-and-knees position can help facilitate fetal rotation from occiput posterior to the desired occiput anterior position. This position utilizes gravity to assist in the repositioning of the baby, ultimately helping to alleviate back pain and promoting more efficient labor progress. It allows the baby's head to descend properly into the pelvis, potentially reducing the risk of a prolonged labor or the need for instrumental delivery. Additionally, being in this position can help the mother feel more comfortable and empowered during labor. Overall, assisting the mother into a hands-and-knees position is a non-invasive, low-risk intervention that can have a positive impact on both the mother and baby's well-being during labor.