When preparing the patient for suctioning, what is the FIRST step?

Correct Answer: D

Rationale: Before any procedure, it is crucial to ensure that you have the proper authorization and guidelines in place. By checking the physician's order and the patient care plan, you confirm that suctioning is indeed needed and that you follow the specific instructions for that patient. This step helps ensure patient safety and effective care delivery. Once you have verified this information, you can proceed with gathering equipment, performing hand hygiene, and assessing the patient's condition as necessary.

Correct Answer: C

Rationale: Ventricular tachycardia (VT) is a potentially life-threatening arrhythmia characterized by wide QRS complexes and absence of P waves on electrocardiogram (ECG). Patients with VT may present with symptoms such as chest pain, dyspnea, and syncope due to reduced cardiac output and ineffective pumping of the heart. VT is a serious condition that requires prompt treatment to prevent hemodynamic compromise and potential cardiac arrest. Stable angina typically presents with chest pain that is provoked by exertion and relieved by rest or nitroglycerin. Atrial fibrillation is characterized by an irregularly irregular rhythm with absent P waves on ECG. Supraventricular tachycardia typically presents with a narrow QRS complex on ECG.

Correct Answer: C

Rationale: Placing the patient on an alternating pressure mattress demonstrates evidence-based practice in pressure injury prevention. Alternating pressure mattresses are designed to change pressure points by alternating pressure across different parts of the body, reducing the risk of pressure injuries. Regularly turning and repositioning the patient (Choice B) is also important in preventing pressure injuries, but an alternating pressure mattress provides additional support and prevention measures. Applying moisturizing lotion (Choice A) and massaging bony prominences (Choice D) may be beneficial for skin care, but they are not proven strategies for pressure injury prevention.

Correct Answer: B

Rationale: The statement "Multigravida patient has shorter labor" is the best response to Patient Josephine's question about her shorter labor compared to previous deliveries. In obstetrics, it is commonly observed that labor tends to be shorter in patients who have had previous pregnancies (multigravida patients) due to factors such as prior cervical changes and previous stretching of the birth canal. This phenomenon is known as "multigravida cervical efficiency," and it can lead to faster and more efficient labors in subsequent pregnancies for women who have had previous deliveries.

Correct Answer: B

Rationale: The symptoms described in the patient, such as tremors, rigidity, bradykinesia (slow movement), and postural instability, along with the presence of a shuffling gait, stooped posture, and masked facies, are classic features of Parkinson's disease. These motor symptoms are primarily caused by the degeneration of dopamine-producing neurons in the substantia nigra region of the brain. This results in an imbalance of neurotransmitters, particularly dopamine, leading to motor dysfunction and characteristic movement abnormalities seen in Parkinson's disease.

Correct Answer: A

Rationale: Administering a stool softener as ordered is the most appropriate nursing intervention for a postpartum client experiencing severe perineal pain and difficulty passing stools following a vaginal delivery. Stool softeners help to soften the stool, making it easier for the client to pass without straining, which can exacerbate perineal pain. It is important to follow the healthcare provider's orders when administering medications to ensure proper dosing and effectiveness. Encouraging the client to refrain from defecation may lead to constipation and worsen the situation. Applying ice packs to the perineum can provide temporary pain relief, but addressing the underlying issue of constipation with a stool softener is more effective in the long term. Providing education on proper perineal hygiene is important for overall postpartum care, but addressing the immediate issue of constipation with a stool softener takes precedence in this scenario.

Correct Answer: D

Rationale: The cough of a patient with lung cancer typically starts off as dry and persistent. This is because lung cancer can irritate the airways, leading to a persistent dry cough as an early symptom. As the cancer progresses, the cough may become more productive with blood-tinged or dark yellow sputum. However, in the early stages, the cough is often dry and persistent, which can be a warning sign for healthcare providers to further investigate potential underlying issues such as lung cancer.

Correct Answer: B

Rationale: The best example of how the nurse can create a climate in which clients do not feel threatened is by teaching on good nutrition while providing a meal. This approach not only addresses an important topic that is beneficial for the clients but also creates a comfortable and welcoming atmosphere. By offering a meal, the nurse is able to engage the clients in a familiar and non-threatening activity, making them more receptive to the information being shared. Additionally, sharing a meal can help to build rapport and create a sense of community among the clients and the nurse, leading to a more positive learning experience.

Correct Answer: D

Rationale: The Somogyi effect, also known as rebound hyperglycemia, is a phenomenon observed in patients with diabetes mellitus during sleep. It is characterized by a low blood sugar level (hypoglycemia) followed by high blood sugar (hyperglycemia) in the morning. This occurs due to limited insulin in the body during the night, leading to high blood sugar levels in the morning as a response to the hypoglycemia episode. Too much globulin or albumin are not directly associated with the Somogyi effect. Increasing insulin in the body would rather help prevent the hypoglycemia episode that triggers the rebound hyperglycemia in the Somogyi effect.