The patient during labor would anticipate some emotional support. Which of the following nursing interventions should Nurse Sarah provide to keep the patient calm?

Correct Answer: B

Rationale: Support in maintaining a sense of control is essential in keeping the patient calm during labor. Giving the patient a sense of control allows them to feel empowered and more in charge of their experience. This can help reduce anxiety and fear, ultimately promoting a more positive and calm labor experience. Providing emotional support by assisting the patient in maintaining control can greatly benefit their overall emotional well-being during this stressful time.

Correct Answer: A

Rationale: Ventilator-associated pneumonia (VAP) is a serious complication in patients receiving mechanical ventilation in the ICU. The priority intervention to manage respiratory infection in a patient with VAP is the administration of appropriate antibiotics to target and eliminate the causative pathogens. Broad-spectrum antibiotics are usually initiated empirically to cover a wide range of potential pathogens commonly associated with VAP, such as Pseudomonas aeruginosa, Staphylococcus aureus, and Acinetobacter species. Timely initiation of antibiotic therapy is crucial in improving outcomes and reducing morbidity and mortality associated with VAP. Other interventions like endotracheal suctioning, oral hygiene measures, and early mobilization are also important in preventing complications and promoting recovery, but the primary focus should be on treating the infection with antibiotics.

Correct Answer: C

Rationale: Nurse Gay should use abbreviations that are part of an approved standard list by the hospital. Using standardized abbreviations ensures clarity, accuracy, and consistency in documentation. It helps in preventing misinterpretation, errors, and ambiguity in patient records. By following an approved list of abbreviations, healthcare professionals can communicate effectively and efficiently while maintaining patient safety and quality of care.

Correct Answer: C

Rationale: If the nurse notices a discrepancy between the patient's identification bracelet and the surgical consent form, the immediate action should be to inform the surgeon and anesthesia provider. It is crucial to address any discrepancies before proceeding with the surgical procedure to ensure patient safety and prevent any potential errors or complications. The surgical team needs to be made aware of the issue so that they can verify the correct patient information and ensure that all necessary steps are taken to proceed safely. Communication and collaboration among the healthcare team members are essential in such situations to prevent any harm to the patient.

Correct Answer: D

Rationale: If a nurse notices a discrepancy between the surgical count and the number of instruments on the sterile field during surgery, it is crucial to inform the surgical team immediately and initiate a thorough search. Patient safety is of utmost importance, and any missing instruments could potentially pose a risk to the patient. By informing the team and conducting a thorough search, the missing instrument can be located promptly to ensure it is not inadvertently left inside the patient's body. Continuing with the procedure or ignoring the discrepancy without further investigation could lead to serious consequences for the patient's well-being. It is always better to address any discrepancies or concerns during surgery proactively to maintain a high standard of patient care and safety.

Correct Answer: B

Rationale: Providing the patient with privacy and assurance of confidentiality is essential to create a safe and trusting environment for open communication. By assuring the patient that their information will be kept confidential, the nurse can help alleviate the patient's fears and encourage them to feel more comfortable discussing their personal health issues. Dismissing the patient's concerns (option A), ignoring their reluctance (option C), or telling them that their embarrassment is unnecessary (option D) are not effective approaches and may further hinder open communication. It is crucial for the nurse to create a supportive and nonjudgmental atmosphere to build trust with the patient and facilitate honest discussions about their health concerns.

Correct Answer: C

Rationale: When a nurse discovers a discrepancy between the medication order and the patient's medication record, the priority action is to verify the medication order with the prescriber to ensure accuracy and patient safety. Administering the medication without clarification can put the patient at risk. Documenting the discrepancy and informing the charge nurse is important, but it should not delay verifying the order with the prescriber. Contacting the pharmacy for clarification may be necessary in some cases, but the immediate action should be to confirm the prescription with the prescriber to prevent errors and ensure the patient receives the correct medication.

Correct Answer: D

Rationale: The engagement of the fetus refers to the baby's head moving down into the mother's pelvis in preparation for birth. This factor is not typically used to distinguish between true and false labor because it is a sign of progress in labor rather than a defining characteristic of true labor. In contrast, the factors that are commonly used to differentiate between true and false labor include contractions (e.g., regularity, intensity, duration), cervical changes observed through vaginal examination (e.g., effacement and dilation), and monitoring vital signs.

Correct Answer: D

Rationale: A hard mass and a reddened area on one breast are key clinical signs that confirm the diagnosis of mastitis. Mastitis is an infection of the breast tissue that often presents with localized redness, warmth, and swelling of the breast. The presence of a hard mass along with the other symptoms suggests inflammation and infection within the breast tissue. In contrast, the other findings such as enlarged glands in the axilla, normal temperature, and engorged breasts are not specific findings for mastitis and may be present in other conditions. Therefore, the presence of a hard mass and reddened area on one breast is the additional finding that strongly confirms the diagnosis of mastitis in this case.