A nurse is caring for a patient who is pregnant. Check the name tag (select all that apply):
Pee privacy
Otoscope
Tannic acid
Pupil dilation
Correct Answer : A
Choice A reason: Pee privacy
Ensuring privacy for a patient, especially one who is pregnant, is crucial. Privacy helps maintain the patient’s dignity and comfort during medical procedures. It also fosters a trusting relationship between the patient and the healthcare provider. In this context, “Pee privacy” likely refers to ensuring the patient has privacy when providing a urine sample, which is a common procedure during pregnancy check-ups to monitor for conditions like gestational diabetes or preeclampsia.
Choice B reason: Otoscope
An otoscope is a medical device used to look into the ears. While it is an essential tool in many medical examinations, it is not specifically related to the care of a pregnant patient unless there is a specific concern about ear health. Therefore, this choice is less relevant in the context of routine pregnancy care.
Choice C reason: Tannic acid
Tannic acid is a substance that can be used for various medical purposes, including treating burns and stopping bleeding. However, it is not typically associated with routine pregnancy care. Its inclusion in this list seems out of place unless there is a specific, unusual medical condition being addressed.
Choice D reason: Pupil dilation
Pupil dilation is a procedure often performed during eye examinations to allow a better view of the retina and other structures inside the eye. While important in ophthalmology, it is not a standard procedure in the care of a pregnant patient unless there is a specific concern about the patient’s vision or eye health.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Metabolic acidosis is characterized by a decrease in blood pH due to an accumulation of acids or a loss of bicarbonate. It can result from conditions such as diabetic ketoacidosis, renal failure, or severe diarrhea. However, it is not typically associated with opioid overdose. Opioid overdose primarily affects the respiratory system, leading to hypoventilation and respiratory acidosis.
Choice B reason: Respiratory acidosis occurs when there is an accumulation of carbon dioxide (CO2) in the blood due to hypoventilation. Opioid overdose depresses the central nervous system, leading to decreased respiratory rate and depth, which causes CO2 retention. This results in a decrease in blood pH, leading to respiratory acidosis. Symptoms may include confusion, lethargy, and shortness of breath.
Choice C reason: Respiratory alkalosis is characterized by a decrease in blood CO2 levels due to hyperventilation. It can occur in conditions such as anxiety, fever, or high altitude. Opioid overdose, however, causes hypoventilation rather than hyperventilation, making respiratory alkalosis an unlikely outcome.
Choice D reason: Metabolic alkalosis is characterized by an increase in blood pH due to an accumulation of bicarbonate or a loss of acids. It can result from conditions such as prolonged vomiting, diuretic use, or excessive bicarbonate intake. Opioid overdose does not typically lead to metabolic alkalosis. The primary concern with opioid overdose is respiratory depression and the resulting respiratory acidosis.
Correct Answer is A
Explanation
Choice A reason: Thrombophlebitis is characterized by inflammation of the vein with the formation of a blood clot. The signs and symptoms include erythema, warmth, edema, and a red line traveling up the vessel, which indicates the presence of inflammation and possible clot formation. This condition requires prompt intervention to prevent further complications such as the spread of infection or the clot traveling to other parts of the body.
Choice B reason: Infiltration occurs when IV fluid or medication leaks into the surrounding tissue. Signs of infiltration include swelling, discomfort, and coolness at the IV site, but it does not typically present with erythema, warmth, or a red line traveling up the vessel. Infiltration is less likely to cause the systemic signs seen in this case.
Choice C reason: Infection at the IV site can cause erythema, warmth, and edema, but it usually does not present with a red line traveling up the vessel. The red line is more indicative of thrombophlebitis, where the inflammation follows the path of the vein. Infection would also likely present with additional systemic signs such as fever.
Choice D reason: Extravasation involves the leakage of vesicant drugs into the surrounding tissue, causing severe local tissue damage. Signs include pain, burning, and blistering at the site, but it does not typically present with a red line traveling up the vessel. Extravasation is more localized and does not follow the vein’s path like thrombophlebitis.
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