While preparing the surgical site, the nurse notices that the skin preparation solution has expired. What should the nurse do?

Correct Answer: C

Rationale: Using an expired skin preparation solution can compromise the safety and effectiveness of the surgical site cleansing. Expired solutions may have reduced efficacy or could cause adverse reactions due to chemical breakdown over time. Therefore, it is essential for the nurse to discard the expired solution and obtain a new one to ensure proper sanitation and reduce the risk of complications during the surgical procedure. It is important to adhere to proper protocols and guidelines in healthcare settings to maintain patient safety and optimal outcomes.

Correct Answer: A

Rationale: Acute respiratory distress syndrome (ARDS) is a serious and life-threatening condition characterized by rapid onset of respiratory failure, severe hypoxemia (low oxygen levels in the blood), and non-cardiogenic pulmonary edema. The hallmark of ARDS is severe hypoxemia that is difficult to correct even with high levels of supplemental oxygen. Patients with ARDS often require mechanical ventilation to maintain adequate oxygen levels. Severe cough with purulent sputum production, chest pain exacerbated by deep breathing, and productive cough with hemoptysis are not typical features of ARDS.

Correct Answer: C

Rationale: Rapid capillary refill is a sign indicative of shock in a trauma patient. Shock is a life-threatening condition where the body's organs and tissues do not receive adequate blood flow and oxygen, leading to cellular damage and eventual organ failure. In a trauma patient, rapid capillary refill suggests poor perfusion, which is a common feature of shock. The capillary refill time is an important clinical assessment that measures the time it takes for color to return to the nail bed after pressure is applied. In cases of shock, the refill time is faster than normal, indicating a systemic circulatory disturbance. Other signs of shock may include tachycardia (increased heart rate), hypotension (not hypertension), and hypothermia (not hyperthermia).

Correct Answer: B

Rationale: A temperature of 39.8 degrees Celsius (103.6 degrees Fahrenheit) in a patient following abdominal surgery and ongoing blood transfusion may indicate an ongoing potential infection. During surgery, the body is exposed to various microorganisms, and the stress of surgery can weaken the immune system, making the patient more susceptible to infections. Blood transfusions also carry a risk of introducing infections if not properly screened. Therefore, in this situation, an elevated temperature may be a sign that an infection is developing, and prompt notification of the surgeon is important for further evaluation and management.

Correct Answer: C

Rationale: Breach of duty is the element of malpractice that occurs when the nurse does not act as a reasonable, prudent person would have acted in a similar circumstance. This means that the nurse failed to uphold the standard of care expected in their practice. In a malpractice case, it must be proven that the nurse breached their duty of care towards the patient by not providing the expected level of skill and care that another reasonable nurse in the same situation would have provided.

Correct Answer: B

Rationale: The correct charting rule to keep the nurse legally safe is to document worries and all concerns as verbalized by the patient (Choice I). This is important for accurately reflecting the patient's condition, communication, and potential interventions. Charting at the end of the shift only (Choice II) is not recommended as it can lead to missed important details or delayed documentation. Discussing recorded cases and diagnoses of the patient (Choice III) breaches patient confidentiality and violates HIPAA laws. Recording all information verbalized by the patient and family (Choice IV) may include unnecessary details and could potentially lead to misinterpretation or misunderstanding, which might not be legally advantageous.

Correct Answer: B

Rationale: When a patient arrives in the emergency room, the nurse's first priority is to assess the patient's airway, breathing, and circulation, following the ABCs of emergency care. In this scenario, positioning the patient with the head lower than the extremities ensures proper blood flow to vital organs, especially the brain. This position helps to maintain perfusion to the brain and prevent complications such as hypotension and shock. Once the patient's position is optimized, the nurse can proceed with further interventions such as starting an intravenous line, stopping bleeding, and requesting laboratory examinations as needed.

Correct Answer: C

Rationale: Prostatitis is characterized by inflammation of the prostate gland, leading to symptoms such as dysuria (painful urination), urinary frequency, urinary urgency, and perineal or pelvic pain. Prostate cancer, on the other hand, is characterized by the presence of malignant cells in the prostate gland and may not present with these typical symptoms. Benign prostatic hyperplasia (BPH) is a non-cancerous enlargement of the prostate gland that can cause urinary symptoms but is not typically associated with inflammation. Urethritis refers to inflammation of the urethra, which is a different condition and may present with symptoms such as painful urination and discharge from the urethra.

Correct Answer: A

Rationale: Atopic dermatitis is a chronic, pruritic inflammatory skin condition that typically presents in individuals with a personal or family history of asthma and allergic rhinitis (hay fever). The characteristic presentation includes erythematous papules, vesicles, and excoriations on the flexural surfaces of the elbows and knees. This type of dermatitis is commonly seen in patients with atopy, which refers to a genetic predisposition to develop allergic diseases like asthma, hay fever, and eczema. Therefore, given the patient's personal history of asthma and hay fever along with the described rash distribution and appearance, atopic dermatitis is the most likely diagnosis.