The nurse would use bimanual palpation technique in which situation?

Correct Answer: B

Rationale: The correct answer is B) Palpating the kidneys and uterus. The bimanual palpation technique involves using both hands to assess deep structures or organs that cannot be easily palpated with one hand alone. When palpating the kidneys and uterus, this technique allows the nurse to provide support with one hand while using the other hand to feel for the size, shape, and tenderness of these organs. Option A) Palpating the thorax of an infant typically does not require bimanual palpation as the thorax is a superficial structure that can be adequately assessed with one hand. Option C) Assessing pulsations and vibrations can usually be done effectively with a single hand and does not necessarily require the use of bimanual palpation. Option D) Assessing the presence of tenderness and pain can also often be accomplished with a single hand, especially in areas where structures are more superficial. In an educational context, understanding the appropriate use of bimanual palpation is crucial for nurses to accurately assess deep structures and organs. This technique ensures thorough and comprehensive assessments, especially in situations where precise palpation is necessary, such as when examining the kidneys and uterus. Nurses must be knowledgeable about different palpation techniques to provide optimal patient care.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) 3+. Bounding pulses indicate a significant increase in the strength and amplitude of the pulse, often associated with conditions like peripheral vascular disease. This strength is graded on a scale from 0 to 3, with 3+ representing the highest intensity or bounding pulse. Option A) 0 is incorrect because it indicates an absent pulse, which is not the case in this scenario. Options C) 2+ and D) 1+ both represent pulses with varying degrees of strength, but they do not accurately describe the bounding nature of the pulses seen in peripheral vascular disease. Educationally, understanding how to assess and interpret pulses is crucial for healthcare providers, especially in patients with underlying cardiovascular conditions. Recognizing bounding pulses can provide valuable diagnostic information and guide appropriate interventions for the patient's care. It is essential for healthcare professionals to be proficient in assessing vital signs and recognizing abnormalities to provide optimal patient care.

Correct Answer: B

Rationale: In the context of a client with bacterial meningitis, the best choice for a hospital room is Option B) An isolation room three doors from the nurses' station. This option is correct because bacterial meningitis is highly contagious and requires strict isolation precautions to prevent the spread of infection to other patients and healthcare workers. Placing the client in an isolation room helps contain the infectious agent and reduces the risk of transmission. Option A) A private room down the hall from the nurses' station is not the best choice because it does not provide the necessary isolation needed for a client with bacterial meningitis. Option C) A semiprivate room with a 32-year-old client who has viral meningitis is also not appropriate as it can increase the risk of cross-infection between the two clients. Option D) A two-bed room with a client who previously had bacterial meningitis is not ideal as the client may still be a carrier of the bacteria and pose a risk of reinfection. From an educational standpoint, this scenario highlights the importance of understanding the specific isolation requirements for infectious diseases and the critical role of infection control measures in preventing the spread of communicable diseases in healthcare settings. Healthcare professionals must be knowledgeable about proper isolation protocols to ensure the safety of both patients and staff members.

Correct Answer: C

Rationale: The correct answer is C) A 46-year-old patient who was admitted 48 hours ago with bacterial meningitis and has an antibiotic dose due. This patient is the best choice for the RN floated from the medical unit because they require timely administration of antibiotics for their bacterial meningitis. This task aligns closely with the medical unit's scope of practice, as administering medications is a common nursing responsibility in that setting. Option A) involves a patient with a basilar skull fracture and clear drainage, which may require neurologic assessments and interventions beyond the typical scope of a medical unit RN. Option B) presents a patient with a ruptured berry aneurysm, a complex neurologic condition that necessitates specialized care and monitoring. Option D) features a patient with an astrocytoma post-craniotomy, requiring neurologic surveillance and expertise that exceed the capabilities of a medical unit RN. By selecting option C, the RN from the medical unit can effectively contribute to the care of a patient needing medication administration, a task well within their competency level. This scenario provides a valuable educational context by highlighting the importance of aligning nursing assignments with staff competencies to ensure safe and effective patient care.

Correct Answer: C

Rationale: In this scenario, the correct answer is C) Prosthetic valve replacement. The reason for this is that individuals with certain metallic implants or devices, such as prosthetic heart valves, pacemakers, or other metallic objects in their bodies, may not be eligible for magnetic resonance imaging (MRI) due to the risk of interference with the magnetic field of the machine. Option A) Hypertension, Option B) Heart failure, and Option D) Chronic obstructive pulmonary disorder do not typically preclude a patient from undergoing an MRI procedure. Hypertension, heart failure, and COPD are common health conditions that are not contraindications for MRI. Educationally, this question highlights the importance of understanding contraindications to specific diagnostic procedures based on a patient's medical history. Nurses need to be aware of these contraindications to ensure patient safety and the accuracy of diagnostic tests. This knowledge helps in providing optimal care and preventing potential risks or complications for patients undergoing medical procedures.