You accidentally touch Claudia's eyelid during eye drop instillation causing her to blink. What should have you done to prevent this from occurring?

Correct Answer: B

Rationale: Tilt back Claudia's head slightly would have been the correct action to prevent her from blinking during eye drop instillation. By tilting her head back, you create a more stable position for instilling the eye drops, reducing the likelihood of accidental contact with her eyelid. Additionally, tilting the head back slightly helps in making it easier for the drops to enter the eye and stay within the conjunctival sac, improving the efficacy of the medication.

Correct Answer: D

Rationale: When performing an intramuscular (IM) injection, the nurse should insert the needle at a 90-degree angle into the muscle. This angle helps ensure proper and deep penetration into the muscle tissue for effective administration of the medication. It also helps prevent leakage or tissue damage at the injection site. Additionally, inserting the needle at a 90-degree angle facilitates accurate delivery of the medication into the muscle where it can be absorbed properly. Therefore, selecting the correct angle for inserting the needle is critical in ensuring the success and effectiveness of the IM injection.

Correct Answer: C

Rationale: Nurse Minda should alert the unit staff to closely observe the fan because the occasional sparking may be a sign of an impending issue that could lead to a more serious problem. By closely monitoring the fan, the staff can ensure the safety of those in the unit and take necessary actions if the situation worsens. It is important to address potential safety hazards promptly to prevent any harm or damage.

Correct Answer: A

Rationale: Betamethasone (Celestone) is a corticosteroid medication that is commonly used to promote fetal lung maturity in pregnant women at risk of preterm delivery. Administering betamethasone to the mother helps accelerate the production of surfactant in the fetal lungs, which is essential for proper lung function and development. This medication is typically given to pregnant women between 24 and 34 weeks of gestation to reduce the risk of respiratory distress syndrome in preterm infants. It does not prevent premature closure of the ductus arteriosus, delay delivery, or stop premature uterine contractions.

Correct Answer: C

Rationale: The right to anonymity is the basic human right that exists when the subject's identity cannot be linked, even by the researcher, with his or her individual responses. Anonymity ensures that individuals can freely express their thoughts, opinions, and experiences without fear of being identified or facing any consequences. It is crucial in research to protect the privacy and confidentiality of participants, build trust, and encourage honest responses. Anonymity is a fundamental ethical principle in research to safeguard the rights and well-being of participants.

Correct Answer: A

Rationale: While it is important for nurse leaders to seek input and feedback from staff members, the inappropriate aspect of this action lies in the lack of clarity. The option contains a typographical error "natter" instead of "matter," which may lead to confusion and hinder effective communication. Additionally, the word choice of "opinion" instead of a more structured and strategic approach like "feedback" or "input" could be improved for professional communication in the workplace. Therefore, this action may not be considered appropriate in a work setting due to potential misunderstandings that can arise from the lack of clarity in communication.

Correct Answer: C

Rationale: When a pregnant woman is diagnosed with preeclampsia, the focus of health care shifts to the individual woman herself. Preeclampsia is a serious condition that affects the health of the pregnant woman and her unborn child. The healthcare team will prioritize the care and treatment of the woman to ensure her well-being and safety. In this scenario, the emphasis is on providing personalized and targeted care to address the needs of the individual patient, rather than a broader focus on population groups, communities, or families.

Correct Answer: C

Rationale: Choosing option C, asking the patient about their cultural beliefs and preferences related to pain, demonstrates cultural competence in pain assessment. Pain experiences can vary greatly across different cultures, and a patient's cultural background can influence how they perceive and express pain. By inquiring about the patient's cultural beliefs and preferences, the nurse can gain a better understanding of the patient's perspective on pain. This information is crucial for providing individualized and culturally sensitive pain management interventions. It also shows respect for the patient's unique cultural background and helps build a trusting and collaborative relationship between the nurse and the patient.

Correct Answer: B

Rationale: The correct action for the nurse to ensure proper insertion technique during a urinary catheterization is to use aseptic technique and sterile equipment. This is crucial in preventing infections and ensuring patient safety. Aseptic technique involves maintaining cleanliness and preventing the introduction of harmful microorganisms during invasive procedures like catheterization. Using sterile equipment helps minimize the risk of introducing bacteria into the urinary tract, which could lead to a urinary tract infection (UTI). Therefore, it is essential that the nurse follows strict infection control protocols and uses sterile equipment to maintain patient safety and well-being during the catheterization procedure.