Which is the MOST appropriate intervention should the nurse do to help family perform the health tasks?

Correct Answer: B

Rationale: Helping the family recognize the problem is the most appropriate intervention to assist them in performing health tasks. By recognizing the problem, the family can better understand the need for action and be motivated to take steps to address it. This intervention enables the family to become more engaged in their healthcare decision-making process and enhances their ability to effectively manage their health tasks. It empowers them to seek appropriate health resources and make informed choices in promoting their health and well-being. Ultimately, by acknowledging the problem, the family is better equipped to initiate positive changes and improve their overall health outcomes.

Correct Answer: D

Rationale: Bronze baby syndrome is the term used to describe the transient discoloration of a baby's skin while undergoing phototherapy treatment for jaundice. This phenomenon typically occurs in preterm infants and is believed to be caused by the breakdown of bilirubin into colored pigments during phototherapy. The discoloration can range from a bronze or brownish color to a grayish-green hue. One key characteristic of bronze baby syndrome is that the discoloration is reversible once phototherapy is complete and does not indicate any underlying health concerns. It is important for healthcare providers to be aware of this phenomenon to avoid unnecessary interventions or alarm to the caregivers.

Correct Answer: A

Rationale: The patient's presentation of fatigue, weakness, jaundice, elevated indirect bilirubin levels, reticulocytosis, and positive Coombs test is consistent with hemolytic anemia. Among the options provided, hereditary spherocytosis is the most likely condition to cause these findings.

Correct Answer: B

Rationale: The formulation of a vision and mission statement in a health facility is an essential aspect of leadership and management. A well-crafted vision and mission statement provide the organization with a clear direction and purpose, guiding management and health personnel in their daily activities. It helps in aligning individual goals with organizational objectives, fostering teamwork, and enhancing overall performance. Effective leadership and management ensure that the vision and mission are communicated effectively, understood by all stakeholders, and implemented throughout the organization to achieve quality standards. By setting the tone for organizational culture and values, leadership and management play a crucial role in shaping the quality of care and services provided by the health facility.

Correct Answer: A

Rationale: After activating the emergency response system, the immediate priority in CPR is to begin chest compressions to support blood circulation. High-quality chest compressions are crucial in providing oxygen to vital organs, especially the brain, during cardiac arrest. Starting chest compressions promptly can improve the chances of survival for the person in need of CPR. Checking for breathing, performing abdominal thrusts, or assessing pulse should only be done after initiating chest compressions in the CPR sequence.

Correct Answer: D

Rationale: The correct advice to give to the owner of the dog in case of a dog bite is to feed the dog well and observe its behavior closely. It is not necessary to give away, impound, or kill the dog immediately after a bite incident. By feeding the dog well and observing its behavior, the owner can see if there are any underlying issues that may have caused the dog to bite. Additionally, observing the dog can help the owner determine if the dog has any health issues that need to be addressed. This approach allows the owner to make an informed decision about the dog's future while ensuring the safety of others.

Correct Answer: B

Rationale: The nurse's best response when a patient asks about alternative treatment options is to provide the patient with information about those options, including their benefits and risks. It is important for the nurse to support the patient in their exploration of different treatment approaches and empower them to make informed decisions about their care. Dismissing the question, ignoring it, or discouraging alternative treatments are not appropriate responses and may hinder the patient's ability to make choices that align with their values and preferences. Therefore, providing information and facilitating an open discussion about alternative treatments is the most appropriate approach for the patient's best interest.

Correct Answer: B

Rationale: Patient's uterine contractions lasting 70 seconds and occurring every 90 seconds signify hyperstimulation, which can be a serious complication associated with oxytocin administration. This may result in decreased uterine perfusion, fetal distress, and other adverse effects. The first action should be to discontinue the oxytocin infusion to prevent further complications and allow the uterus to relax. Observations and assessment should continue to monitor the patient's condition and response after discontinuing the infusion. Giving an emergency bolus of oxytocin or increasing the IV infusion rate would exacerbate the hyperstimulation, and turning the client to her left side and breathing deeply would not address the underlying issue of oxytocin-induced hyperstimulation.

Correct Answer: C

Rationale: It is crucial to ensure that the autoclave is functioning properly to achieve proper sterilization of surgical instruments. If the autoclave is not reaching the required temperature, it signifies a technical issue that needs to be addressed promptly. The nurse should notify the sterile processing department immediately and request maintenance to investigate and resolve the problem. Continuing with sterilization without addressing the temperature issue can compromise the effectiveness of sterilization and pose a risk of infection to patients. Adjusting the settings on the autoclave or using an alternative method of sterilization are not appropriate actions in this situation.