Nurse Nora observes that the Ellie's uterine contractions are irregular in frequency and short in duration. Ellie screams in pain during contractions. Which of the following actions is considered BEST for the nurse to perform?

Correct Answer: B

Rationale: Administering pain relief medication as ordered is the best action for the nurse to take in this situation where the patient is experiencing intense pain during irregular and short uterine contractions. Pain relief medications can help alleviate the discomfort and distress that Ellie is experiencing, providing her with much-needed relief and improving her overall comfort during labor. It is important for the nurse to follow the prescribed orders for pain relief medication to ensure safe and effective pain management for the patient.

Correct Answer: A

Rationale: A tension pneumothorax is a life-threatening condition where air accumulates in the pleural space and cannot escape, causing increased pressure in the chest cavity. This can lead to compression of the lung and major blood vessels, leading to inadequate oxygenation and circulation.

Correct Answer: C

Rationale: Nitroglycerin sublingual tablets are meant to be dissolved under the tongue to allow for rapid absorption into the bloodstream. Placing the tablet under the tongue helps to bypass the first-pass metabolism in the liver, leading to a quicker onset of action and chest pain relief. Chewing, swallowing, or applying the tablet to the skin will result in decreased effectiveness or delayed onset of action. Therefore, it is important for the patient to be instructed to place the nitroglycerin tablet under the tongue and allow it to dissolve for optimal therapeutic benefit.

Correct Answer: D

Rationale: Administering oxygen inhalation is the priority nursing action for a patient presenting with clinical manifestations related to endocrine disorders. Patients with hyperthyroidism, Cushing syndrome, and hypothyroidism can all experience respiratory distress due to various reasons such as thyroid storm, adrenal crisis, or myxedema coma. Oxygen inhalation helps improve oxygenation and tissue perfusion, providing immediate support to the patient's respiratory system. It is crucial to ensure adequate oxygenation before addressing other assessments or interventions. Once the patient's breathing is stabilized, further assessments and treatments can be initiated as necessary.

Correct Answer: B

Rationale: The correct action for the nurse to ensure proper insertion technique during a urinary catheterization is to use aseptic technique and sterile equipment. This is crucial in preventing infections and ensuring patient safety. Aseptic technique involves maintaining cleanliness and preventing the introduction of harmful microorganisms during invasive procedures like catheterization. Using sterile equipment helps minimize the risk of introducing bacteria into the urinary tract, which could lead to a urinary tract infection (UTI). Therefore, it is essential that the nurse follows strict infection control protocols and uses sterile equipment to maintain patient safety and well-being during the catheterization procedure.

Correct Answer: A

Rationale: ORNAP stands for Operating Room Nurses Association of the Philippines, which is an appropriate professional organization for Merle to actively join after 3 years of experience in the Operating Room. ORNAP is dedicated to promoting professional growth and development, advancing the standards of perioperative nursing practice, and providing a platform for networking and collaboration among operating room nurses in the Philippines. By becoming a member of ORNAP, Merle can stay updated on the latest trends and best practices in perioperative nursing, participate in continuing education opportunities, and connect with colleagues in the same field to enhance her skills and knowledge.

Correct Answer: A

Rationale: In this critical situation, the safety of the wife is of utmost importance. Whenever a healthcare provider becomes aware of a direct threat to someone's safety, especially related to potential harm or violence, it is their ethical and legal responsibility to report this information to the appropriate authorities promptly. In this case, the nurse should alert the proper authorities, such as law enforcement or a mental health crisis team, to ensure that immediate steps are taken to protect the wife from harm. Confidentiality should be breached in situations where there is a clear threat to an individual's safety. Keeping the information confidential in this scenario could result in serious harm or even loss of life. The nurse must act quickly to protect the potential victim.

Correct Answer: D

Rationale: Nurse Noli should not advise patients to eat more saturated fats. Saturated fats are known to increase cholesterol levels and can lead to heart disease and other health issues. It is recommended to limit the intake of saturated fats in the diet. Therefore, advising patients to eat more saturated fats goes against the goal of promoting heart-healthy habits. Instead, Nurse Noli should focus on encouraging patients to cut down on salt intake, consume more fruits and vegetables, and eat regular meals to maintain a balanced and healthy diet.

Correct Answer: C

Rationale: The health care team will try the oral route first for Ms. C for delivering nutrition and fluid because it is the most natural and least invasive method. If the patient is able to tolerate oral intake and has adequate oral intake, it is typically the preferred route. Only if she is unable to meet her nutritional needs orally or has difficulty swallowing, then alternative routes such as nasogastric tube, gastrostomy tube, or intravenous routes may be considered. It's important to promote oral intake whenever possible to maintain the patient's quality of life and prevent complications associated with more invasive methods.