In case of poisoning, the nurse is aware that the main goals in poisoning are to ________. I. inactivate the poison II. administer the specific antidote III. induce the patient to vomit IV. support vital organ functions

Correct Answer: A

Rationale: In cases of poisoning, the main goals are to inactivate the poison to prevent further harm, administer the specific antidote if available to counteract the effects of the poison, and support vital organ functions to help the patient recover. Inducing the patient to vomit (III) is not always recommended as it can potentially cause more harm, especially if the ingested substance is corrosive. Therefore, the most appropriate goals in poisoning are to inactivate the poison, administer the specific antidote, and support vital organ functions.

Correct Answer: B

Rationale: In this scenario, the firm and midline fundus at three hours postpartum indicates that the uterus is contracting well. The presence of a small constant trickle of blood on perineal inspection suggests ongoing bleeding. This combination of findings is concerning for retained placenta, where a portion of the placenta remains attached to the uterine wall and prevents proper contraction and closure of the blood vessels at the placental site. Retained placenta can lead to postpartum hemorrhage and requires prompt evaluation and intervention to prevent complications. Nurse Kayla should escalate this finding to the healthcare provider for further assessment and management.

Correct Answer: D

Rationale: Upon clinical assessment, the nurse observes that the outstanding manifestation of the patient is edema. Edema is characterized by the accumulation of excess fluid in the body's tissues, leading to swelling. Edema can be a sign of various health conditions, such as heart failure, kidney disease, liver disease, or injury. It is crucial to identify and address the underlying cause of edema promptly to prevent complications and provide appropriate treatment for the patient.

Correct Answer: D

Rationale: In a longitudinal study design, the nurse researcher collects data at multiple points over an extended period of time. This design allows for the examination of changes or trends over time within the same group of participants. It helps in understanding the long-term effects and relationships between variables by tracking the same individuals over a prolonged duration. This design is particularly useful in studying developmental patterns, chronic diseases, or long-term treatment outcomes.

Correct Answer: A

Rationale: The theory that categorizes professionals as Novice to experts is by Patricia Benner. Patricia Benner developed the Novice to Expert model, which describes how individuals progress through five levels of proficiency in a skill or field. The five levels are Novice, Advanced Beginner, Competent, Proficient, and Expert. Benner's model is widely used in nursing education and research to understand how nurses develop their clinical skills and expertise over time.

Correct Answer: B

Rationale: In a situation where a patient's temperature is dropping below the normal range during surgery, the nurse should prioritize actively warming the patient to prevent hypothermia. Administering a warming blanket or using a forced-air warming device are effective methods to increase the patient's body temperature and prevent any complications that may arise from hypothermia. Increasing the ambient room temperature can help, but it may not be as direct or effective as applying targeted heat sources to the patient. Documenting the temperature trend in the patient's chart is important for record-keeping purposes, but immediate action to address the dropping temperature is necessary. Continuously monitoring the patient's temperature closely is important, but action should be taken promptly to prevent further decline.

Correct Answer: D

Rationale: During the active phase of labor, a cervical dilation of 6 cm and regular contractions lasting 60 seconds each, occurring every 3 minutes indicate good progress in labor. The nurse should continue to monitor the progress closely by assessing the mother's vital signs, fetal heart rate, and the pattern of contractions. It is important to provide support and encouragement to the mother, continue with comfort measures, and be prepared to assist with the delivery when the cervix is fully dilated. This stage of labor is focused on active dilation and effacement of the cervix, and it is not yet time for the mother to push or for the nurse to administer oxytocin to augment labor.

Correct Answer: C

Rationale: The correct response for the nurse in this situation would be to offer the victim a shower after evidence is collected. It is essential to preserve any physical evidence that may be present from the assault during the forensic examination. Allowing the victim to shower before evidence is collected could potentially compromise the evidence and hinder the investigation. The nurse should provide support to the victim during this difficult time and assure them that they will have the opportunity to shower once the necessary evidence is obtained. It is also crucial for the nurse to offer empathy and understanding while explaining the importance of preserving any evidence related to the assault.

Correct Answer: B

Rationale: When a nurse is delegating tasks to a nursing assistant, the principle that should guide the nurse's delegation decisions is assigning tasks based on the assistant's level of experience (Option B). It is essential to take into consideration the skills, competencies, and experience level of the nursing assistant to ensure that the tasks delegated are suitable for them to perform safely and effectively. Delegating tasks beyond the assistant's level of experience may result in errors, inefficiencies, or compromised patient care. Therefore, matching tasks with the assistant's experience level is crucial in successful delegation and providing quality patient care.