Nokea
Select the 2 findings that require immediate follow-up.
- A. Blood pressure
- B. Duration of contraction
- C. Fetal heart rate
- D. Fetal station
- E. Characteristics of amniotic fluid
Correct Answer: C,E
Rationale: An elevated fetal heart rate and meconium-stained amniotic fluid indicate potential distress, necessitating urgent intervention.
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Which of the following actions is appropriate for the nurse to take?
- A. Add medication directly to enteral feeding
- B. Dissolve the medication together
- C. Use a syringe to allow the medications to flow by gravity
- D. Flush the NG tube with 5 ml water
Correct Answer: D
Rationale: The correct answer is D: Flush the NG tube with 5 ml water. This action is appropriate because flushing the NG tube with water helps prevent clogging and ensures proper medication administration. Adding medication directly to enteral feeding (choice A) can lead to tube clogging. Dissolving medications together (choice B) can alter their effectiveness. Using a syringe to allow medications to flow by gravity (choice C) may not be sufficient for complete administration. Flushing the NG tube with water (choice D) maintains tube patency. No further choices provided.
The nurse should set the IV infusion to deliver how many ml/hr?
- A. mL/hr
- B. 11.0 mL/hr
- C. 6.0 mL/hr
- D. 16.0 mL/hr
Correct Answer: B
Rationale: The correct answer is B: 11.0 mL/hr. This is the correct answer because the question asks how many mL/hr the nurse should set the IV infusion to deliver. The specific rate of 11.0 mL/hr is likely calculated based on the patient's individual needs, prescribed fluid volume, and the desired rate of administration. Option A is too general and does not provide a specific rate. Options C and D are incorrect as they do not match the recommended rate of 11.0 mL/hr given in the question.
Which action should the nurse take?
- A. Identify possible precipitating factors related to the infection
- B. Reinforce proper hand hygiene practices among staff.
- C. Implement a protocol for timely removal of unnecessary catheters.
- D. Provide staff education on aseptic catheter insertion techniques.
- E. Conduct regular audits on catheter care compliance.
Correct Answer: E
Rationale: The correct action for the nurse to take is E: Conduct regular audits on catheter care compliance. Audits help monitor adherence to catheter care protocols, identify areas needing improvement, and ensure staff follow best practices consistently. This action promotes quality care, reduces infection risks, and enhances patient safety. Choices A, B, C, and D are important but do not directly address ongoing monitoring and assessment of compliance like regular audits do. Conducting audits is a proactive approach to continuously evaluate and improve catheter care practices, making it the most appropriate action in this scenario.
Which of the following actions should the nurse take to reduce the risk for client injury?
- A. Keep the television on during the night
- B. Place the bedside table at the foot of the bed
- C. Raise the side rails up when the client is in bed
- D. Assist the client to the toilet frequently
Correct Answer: C
Rationale: The correct answer is C: Raise the side rails up when the client is in bed. This action helps prevent falls and injuries by providing a physical barrier to keep the client from rolling out of bed. Keeping the television on (choice A) does not directly address client safety. Placing the bedside table at the foot of the bed (choice B) may not prevent falls or injuries. Assisting the client to the toilet frequently (choice D) is important for personal care but does not directly reduce the risk for client injury.
Which laboratory test should the nurse report?
- A. INR
- B. Prothrombin time (PT)
- C. Activated partial thromboplastin time (aPTT)
- D. Platelet count
- E. Hemoglobin and hematocrit levels
Correct Answer: A
Rationale: The correct answer is A: INR. The nurse should report the INR (International Normalized Ratio) test because it specifically measures the effectiveness of anticoagulant therapy like warfarin. A high INR indicates a higher risk of bleeding, while a low INR indicates a higher risk of clotting. Reporting the INR can help healthcare providers adjust medication dosage to maintain optimal therapeutic levels.
Incorrect choices:
B: Prothrombin time (PT) is related to INR but is less specific for monitoring anticoagulant therapy.
C: Activated partial thromboplastin time (aPTT) is used to monitor heparin therapy, not warfarin.
D: Platelet count assesses the number of platelets, not the effectiveness of anticoagulant therapy.
E: Hemoglobin and hematocrit levels assess blood volume and oxygen-carrying capacity, not anticoagulant therapy.