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: B

Rationale: The statement provided clearly outlines the expectation regarding the dress code in the facility. By explicitly mentioning that wearing blue jeans while on duty is not included in the dress code, the individual is being informed about a specific expectation they are expected to adhere to. Stating expectations is a crucial step in giving constructive criticism as it sets a clear standard for behavior or performance. In this case, by mentioning the dress code policy, it helps guide the individual on what is acceptable and what is not when it comes to attire while at work.

Correct Answer: B

Rationale: In an educational program conducted by a nurse, it is crucial to involve the patient, their family, and significant others. This approach ensures holistic care by considering the patient's psychosocial environment, family dynamics, and support system. Including these individuals in the educational program fosters collaboration, strengthens the patient-nurse relationship, and equips family members with the knowledge and skills needed to provide optimal care at home. Furthermore, involving the patient's support system can enhance adherence to treatment plans and contribute to better health outcomes. Therefore, the presence and cooperation of the patient, family, and significant others are essential elements of a successful educational program led by a nurse.

Correct Answer: C

Rationale: A discectomy is a surgical procedure commonly performed to decompress the nerve root by removing a portion of the herniated disc that is pressing on the nerve. In cases of herniated discs causing radicular symptoms (such as pain radiating down the leg), a discectomy can help alleviate the compression on the nerve, reduce symptoms, and improve the patient's condition. This procedure involves removing the portion of the disc that is herniated or bulging out to relieve pressure on the nerve root, allowing for improved function and reduced pain. Spinal fusion, laminectomy, and foraminotomy are other surgical procedures that are not typically performed for the direct decompression of the nerve root in cases of herniated discs at a specific level like the L5-S1 level.

Correct Answer: B

Rationale: Nurse Chona should explain to Patient Noel that the sign of negative before the word means that he is not drinking alcohol or smoking cigarettes. This is a simple misunderstanding and clarification should help clear up any confusion. It is important to uphold patient confidentiality and respect their autonomy, rather than reprimanding the patient for looking at their own chart. It is also essential to address any discrepancies in the patient's medical record to ensure accurate information is documented for proper treatment and care.

Correct Answer: D

Rationale: The most appropriate oxygen delivery device for a patient with chronic respiratory failure secondary to severe restrictive lung disease requiring continuous supplemental oxygen is a non-rebreather mask. A non-rebreather mask is designed to deliver high-flow oxygen and is typically used for short-term medical treatment in emergency situations or for critically ill patients. It is ideal for providing the highest concentration of oxygen available for inhalation, making it suitable for patients with severe hypoxemia.

Correct Answer: D

Rationale: When performing an intramuscular (IM) injection, the nurse should insert the needle at a 90-degree angle into the muscle. This angle helps ensure proper and deep penetration into the muscle tissue for effective administration of the medication. It also helps prevent leakage or tissue damage at the injection site. Additionally, inserting the needle at a 90-degree angle facilitates accurate delivery of the medication into the muscle where it can be absorbed properly. Therefore, selecting the correct angle for inserting the needle is critical in ensuring the success and effectiveness of the IM injection.

Correct Answer: E

Rationale: All of the statements (A-D) are true when discussing the testing of vision in infants and children separately from testing in adults. However, statement E is NOT true. The course of visual and cognitive development MUST be taken into account in evaluating infants and children's visual abilities. It is crucial to consider the stage of development a child is in when evaluating their vision, as their visual abilities can change rapidly during early childhood. Ignoring the course of development could lead to incorrect assessments and misunderstandings about the child's visual capabilities.

Correct Answer: B

Rationale: In this scenario, the nurse is asking the patient to elaborate on their feelings and thoughts related to the upcoming surgery. By asking, "What do you fear MOST about your surgery tomorrow?" the nurse is seeking clarification to better understand the patient's concerns and enable effective communication. Seeking clarification involves asking open-ended questions that encourage the patient to express themselves more fully, allowing the healthcare provider to address their specific worries or needs more effectively.