Nurse Selma is preparing to administer ofloxacin eardrop on Catherine per Doctor's order. She needs to hold the bottle with her hands to warm up the solution to prevent dizziness for

Correct Answer: B

Rationale: Warming up ofloxacin eardrops before administering is done to prevent dizziness, which can occur if a cold solution is placed in the ear. Holding the bottle with hands for about 1 to 2 minutes is usually sufficient to warm up the solution to a comfortable temperature for the patient. Warming the solution for too long, such as 5-6 minutes, may not be necessary and could potentially waste time. So, the correct duration for warming up ofloxacin eardrops is 1 to 2 minutes.

Correct Answer: B

Rationale: In the case of umbilical cord prolapse, the priority nursing action is to prepare for an immediate cesarean section. Umbilical cord prolapse is a serious obstetric emergency where the umbilical cord slips through the cervix ahead of the presenting part of the fetus. This can lead to compression of the cord, compromising fetal blood flow and oxygenation. Immediate delivery via cesarean section is necessary in order to prevent fetal hypoxia and avoid potential complications such as brain damage or death. Elevating the mother's hips or administering intravenous fluids rapidly may be interventions done in conjunction with preparing for a cesarean section, but the priority remains expedited delivery of the baby. Applying external fetal monitoring is not the most appropriate action in this emergency situation.

Correct Answer: B

Rationale: Monitoring oxygen saturation with pulse oximetry is essential for preventing respiratory depression in a patient prescribed an opioid analgesic. Opioid analgesics can suppress the respiratory drive, leading to respiratory depression. By constantly monitoring the patient's oxygen saturation levels with pulse oximetry, nurses can promptly detect any signs of respiratory depression and intervene early to prevent serious complications. This allows for timely adjustments in the medication dosage or administration of other supportive measures to maintain adequate oxygenation and prevent respiratory compromise. Administering naloxone prophylactically may be necessary in case of an opioid overdose but is not typically done as a preventive measure. Encouraging deep breathing exercises can help prevent respiratory complications postoperatively but may not be sufficient in the presence of opioid-induced respiratory depression. Administering bronchodilators as needed is not directly related to preventing respiratory depression caused by opioid analgesics.

Correct Answer: A

Rationale: The patient's presentation with a blood sugar level of 800mg/dL, absence of ketones in the urine, dehydration, and altered mental status points towards Hyperosmolar nonketotic coma (HNKC). HNKC typically occurs in patients with Type 2 diabetes and is characterized by extremely high blood glucose levels (hyperglycemia) without significant ketosis. The absence of ketones in the urine distinguishes HNKC from Diabetic ketoacidosis (DKA). Patients with HNKC often present with severe dehydration, altered mental status, and hyperosmolarity. It is crucial to address the underlying cause of the hyperglycemia, correct dehydration, and normalize blood glucose levels promptly in the management of HNKC.

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: A

Rationale: The symptoms of irritability, muscle weakness, tremors, weight loss despite increased appetite, along with elevated serum thyroid hormone levels and suppressed TSH levels, are indicative of hyperthyroidism. In hyperthyroidism, the thyroid gland produces an excess amount of thyroid hormone, leading to an overactive metabolism. This results in symptoms such as weight loss, tremors, irritability, and muscle weakness. The elevated levels of thyroid hormone are detected in the laboratory tests, along with low TSH levels due to negative feedback regulation. Therefore, the most likely endocrine disorder responsible for these symptoms is hyperthyroidism.

Correct Answer: A

Rationale: The ultimate purpose of record-keeping is to safeguard information. While history, archiving, and storing information are all important functions of record-keeping, safeguarding information stands out as the primary goal. Keeping accurate and accessible records ensures that essential information is secured, protected from unauthorized access, loss, and damage. Safeguarding information also promotes transparency, accountability, and compliance with legal and ethical standards. In the case of Nurse Mely's consideration of teamwork and collaboration in community health nursing, safeguarding the relevant information through precise and organized record-keeping is crucial for effective communication, continuity of care, and successful health outcomes.

Correct Answer: C

Rationale: The presence of ecchymosis (bruising) and significant swelling in the perineum despite analgesic medication suggests a potential complication such as a hematoma. A hematoma is a collection of blood that can occur due to trauma or during childbirth. It is important to notify the healthcare provider immediately so that further assessment and interventions, such as drainage of the hematoma, can be initiated promptly to prevent complications and alleviate the client's pain. Applying ice packs or encouraging the client to sit on a donut cushion may provide temporary relief but will not address the underlying issue of a potentially serious hematoma. Administering additional analgesic medication may not be effective in this case if the pain is primarily due to the hematoma. Prompt notification of the healthcare provider is crucial for proper management of this situation.

Correct Answer: C

Rationale: The appropriate initial management for a conscious patient experiencing a syncopal episode (fainting) is to provide reassurance and assist the patient to a lying position. This is important to ensure adequate blood flow to the brain and to prevent further injury in case the patient faints again. Elevating the legs above the level of the heart is not recommended as a routine intervention for syncope. Administering intravenous fluids rapidly is not usually needed in the initial management of syncope without signs of dehydration or significant bleeding. Administering oxygen via nasal cannula is not necessary for most cases of syncope unless there are specific indications such as signs of respiratory distress.