One evening, Sonny complained of dyspnea despite continuous oxygen therapy. What should be the FIRST action of the nurse?

Correct Answer: A

Rationale: The FIRST action of the nurse should be to reassess the client experiencing dyspnea despite continuous oxygen therapy. Reassessment would involve checking the client's respiratory status, oxygen saturation levels, vital signs, and overall condition to gather more information about the situation. This will help the nurse identify any potential causes of the dyspnea and determine the appropriate next steps for intervention. Assessing the client before proceeding with any other actions is crucial in providing safe and effective care.

Correct Answer: A

Rationale: The patient's presentation of recurrent episodes of postnasal drip, chronic cough, halitosis, and foul-smelling, yellowish discharge from the middle meatus is highly suggestive of chronic rhinosinusitis. The presence of nasal polyps further supports this diagnosis. Chronic rhinosinusitis with nasal polyps is characterized by inflammation of the paranasal sinuses, leading to symptoms such as nasal congestion, postnasal drip, cough, and a reduced sense of smell. The yellowish discharge and foul odor are typical findings in cases of chronic rhinosinusitis with secondary bacterial infection. Nasal endoscopy may reveal edematous nasal mucosa and polyps obstructing the middle meatus, contributing to the symptoms described by the patient. Management typically involves a combination of medical therapies such as intranasal corticosteroids, saline irrigation, and antibiotics, and in some cases, surgical intervention

Correct Answer: B

Rationale: The most appropriate action for the nurse to take when noticing that the patient seems anxious and is avoiding eye contact is to ask the patient if they are feeling anxious and if they would like to talk about it. This approach shows empathy, concern, and openness to addressing the patient's emotional state. By directly acknowledging the patient's behavior and giving them the opportunity to express their feelings, the nurse can create a supportive and caring environment that promotes effective communication and trust between the patient and healthcare provider. It is important to consider the patient's emotional well-being alongside their physical health during consultations.

Correct Answer: D

Rationale: Quality improvement focuses on proactive measures rather than reactive responses. The medical director would be more interested in establishing processes and systems that prevent issues from occurring in the first place, rather than just reacting to problems as they arise. Continuous improvement involves identifying problems, analyzing root causes, and implementing long-term solutions to prevent the issues from recurring. Therefore, reacting to correct or bad situations is not a characteristic of quality improvement that the medical director would prioritize.

Correct Answer: C

Rationale: In a missed abortion, the embryo has died, but the products of conception remain in the uterus, leading to the visualization of a gestational sac without an embryo on ultrasound. This is a type of missed miscarriage where the woman may not have any symptoms initially and the diagnosis is made during a routine ultrasound. The most common presenting symptom is painless vaginal bleeding. The absence of an embryo within the gestational sac can be confirmed through serial ultrasound examinations showing no fetal growth or cardiac activity. It is important for healthcare providers to provide appropriate counseling and management options to support the patient through this emotional experience.

Correct Answer: A

Rationale: Acute pyelonephritis is the most likely condition based on the patient presentation and urinalysis findings described. Acute pyelonephritis is an infection of the renal parenchyma and pelvis, typically caused by ascending bacteria from the lower urinary tract. The classic symptoms include fever, chills, flank pain, and costovertebral angle tenderness (tenderness over the kidneys). The presence of pyuria (pus in the urine) and bacteriuria (bacteria in the urine) on urinalysis further supports the diagnosis of acute pyelonephritis. It is crucial to diagnose and treat acute pyelonephritis promptly to prevent complications and recurrent infections.

Correct Answer: D

Rationale: It is NOT recommended to use the same syringe and needle in administering two different vaccines. This is to prevent contamination or mixing of different vaccines, which could potentially affect their effectiveness or pose a risk to the individual receiving the vaccines. It is important to use separate syringes and needles for each vaccine to ensure proper administration and prevent any adverse reactions.

Correct Answer: C

Rationale: Uterine rupture is a severe obstetric complication that requires prompt and decisive management to prevent adverse outcomes for both the mother and the baby. In cases of uterine rupture leading to fetal distress and maternal hemorrhage, performing an emergency cesarean section is crucial. This intervention allows for rapid delivery of the baby, relieving the distress on the fetus and enabling immediate access to manage the maternal hemorrhage. By performing a timely cesarean section, healthcare providers can expedite the delivery process and effectively address both the fetal and maternal complications associated with uterine rupture. This intervention is essential in saving lives and reducing the risk of further complications in such a critical obstetric emergency.

Correct Answer: A

Rationale: Prior to a gastric lavage procedure, it is essential for the nurse to ensure the correct size of the nasogastric tube is selected. The appropriate size of the tube will allow for effective removal of the ingested poisonous substance during the procedure. Proper sizing also helps in preventing complications such as injury to the gastrointestinal tract or inadequate removal of the substance. This step is crucial for the safe and successful completion of gastric lavage. Reminding parents to be careful, obtaining informed consent immediately, or accusing them of negligence are not immediate responsibilities of the nurse in this context.