Which of the following interventions is most appropriate for a patient experiencing an acute asthma exacerbation with severe respiratory distress and hypoxemia?

Correct Answer: B

Rationale: In a patient experiencing an acute asthma exacerbation with severe respiratory distress and hypoxemia, the most appropriate intervention is to initiate non-invasive positive pressure ventilation (NIPPV). NIPPV can help improve ventilation, decrease work of breathing, and correct hypoxemia by providing positive pressure to keep the airways open, reduce air trapping, and increase the elimination of carbon dioxide. This intervention can help improve oxygenation and reduce the need for invasive mechanical ventilation in patients with severe asthma exacerbations. Administering high-flow oxygen via nasal cannula alone may not provide enough support for patients with severe respiratory distress. Nebulized albuterol/ipratropium combination therapy and intravenous corticosteroid therapy are also important treatments for asthma exacerbations but are not the first-line interventions for patients with severe respiratory distress and hypoxemia.

Correct Answer: B

Rationale: Malpractice is a type of tort that involves professional negligence or misconduct by a professional such as a nurse that results in harm to a patient. In this scenario, failing to obtain informed consent before performing a procedure is considered a breach of the standard of care expected from a healthcare professional, which falls under malpractice. This failure to obtain informed consent deprives the patient of the right to make an informed decision about their treatment and can lead to legal consequences for the nurse.

Correct Answer: B

Rationale: The nurse's priority action after noticing a sudden drop in blood pressure after administering anesthesia is to assess the patient's airway, breathing, and circulation (ABCs). This is crucial to determine the immediate cause of the sudden drop in blood pressure and to ensure the patient's safety and stability. Assessment of the ABCs will help identify any potential airway obstruction, respiratory distress, or circulatory issues that may be contributing to the drop in blood pressure. Once the assessment is done, appropriate interventions can be initiated to stabilize the patient's condition. Administering vasopressors, documenting the blood pressure readings, and notifying the anesthesiologist are important actions but assessing the ABCs takes precedence in this situation to ensure the patient's immediate needs are addressed.

Correct Answer: C

Rationale: In assigning rooms for the injured patients, the most appropriate and compassionate choice is to have mother and child together in one room. This decision prioritizes the well-being and emotional support for the child, as having the mother nearby can have a positive impact on the child's recovery. It also promotes family bonding during a difficult time, which can aid in the healing process. Additionally, the presence of a parent can provide comfort and reassurance to the child, contributing to a more positive hospital experience. Therefore, it is important for the nurses to coordinate with the Administration to ensure that mother and child are assigned to the same room whenever possible.

Correct Answer: B

Rationale: Ella's statement "I will hang myself" directly indicates a desire and intent to commit suicide. This is classified as a suicidal intent, which is a serious concern that requires immediate attention and intervention. It is crucial to take any mention or indication of suicide seriously and seek help from mental health professionals or crisis intervention services.

Correct Answer: C

Rationale: Mastitis is an infection of the breast tissue that may occur in postpartum clients. When a postpartum client exhibits signs of mastitis, including breast tenderness, erythema, and warmth, it is crucial to notify the healthcare provider immediately. Prompt medical evaluation is necessary to determine the appropriate treatment plan, which may include antibiotics. Delay in treatment can lead to complications, such as abscess formation. Encouraging the client to continue breastfeeding and applying warm compresses may provide some relief but do not address the underlying infection. Administering oral antibiotics would require a prescription from the healthcare provider, hence notifying the provider is the most appropriate initial nursing action in this situation.

Correct Answer: A

Rationale: Rhinitis is inflammation of the nasal mucosa, and common clinical manifestations include nasal congestion (blockage or stuffiness), rhinorrhea (runny nose), and sneezing. These symptoms are often present in both allergic and non-allergic rhinitis. While headaches, sore throat, and fever can occur in some cases, they are not as specific to rhinitis as nasal congestion, rhinorrhea, and sneezing.

Correct Answer: B

Rationale: Performing a sigmoidoscopy, which is a procedure to examine the lower part of the colon and rectum, during a health screening event at a community center may not be practical for several reasons. Firstly, sigmoidoscopy is relatively invasive compared to other screening methods for colon cancer, such as fecal occult blood tests or colonoscopy. Secondly, it can be expensive to perform, especially in a community setting where cost-effectiveness is an important consideration. Therefore, Nurse Filomena would likely point out the invasiveness and cost factors to explain why a sigmoidoscopy may not be suitable for a health screening event at a local community center.

Correct Answer: C

Rationale: A dental abscess is characterized by a localized collection of pus that results from a bacterial infection of the tooth pulp, leading to swelling, pain, and inflammation. The infection typically occurs when bacteria enter the tooth through a cavity, crack, or other dental injury. The abscess can cause significant pain and discomfort and must be treated promptly by a dentist to prevent further complications. Dental caries refer to tooth decay or cavities that result from the breakdown of tooth structure by acids produced by bacteria. Periodontitis is a severe gum infection that damages the soft tissue and destroys the bone that supports the teeth. Oral candidiasis is a fungal infection that affects the mouth and throat.