Nokea
A client arrives in the emergency room with severe burns of the hands, right arm, face, and neck. The nurse needs to start an IV.
- A. Top of client's right hand
- B. Left antecubital fossa
- C. Top of either foot
- D. Left forearm
Correct Answer: B
Rationale: The left antecubital fossa is suitable for IV placement, avoiding burned areas (right hand, arm, face, neck). The foot (C) is less ideal due to infection risk, and the left forearm (D) may be too close to burn sites.
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The obstetric client's fetal heart rate is 80-90 during the contractions. The first action the nurse should take is:
- A. Reposition the monitor
- B. Turn the client to her left side
- C. Ask the client to ambulate
- D. Prepare the client for delivery
Correct Answer: B
Rationale: A fetal heart rate of 80-90 during contractions indicates bradycardia possibly from cord compression or uteroplacental insufficiency. Turning the client to her left side improves placental perfusion and is the first action.
A client develops an intestinal obstruction postoperatively. A nasogastric tube is attached to low, intermittent suction with orders to 'Irrigate NG tube with sterile saline q1h and prn.' The rationale for using sterile saline, as opposed to using sterile water to irrigate the NG tube is:
- A. Water will deplete electrolytes resulting in metabolic acidosis.
- B. Saline will reduce the risk of severe, colicky abdominal pain during NG irrigation.
- C. Water is not isotonic and will increase restlessness and insomnia in the immediate postoperative period.
- D. Saline will increase peristalsis in the bowel.
Correct Answer: A
Rationale: Water is a hypotonic solution and will deplete electrolytes and cause metabolic acidosis when used for nasogastric irrigation. Irrigating with saline does not cause abdominal discomfort. Severe, colicky abdominal pain is a symptom of intestinal obstruction. Irrigating with water will not cause restlessness or insomnia in the postoperative client. Restlessness and insomnia can be emotional complications of surgery. A nasogastric tube placed in the stomach is used to decompress the bowel. Irrigating with saline ensures a patent, well-functioning tube. Irrigating with saline will not increase peristalsis.
Prior to administering digoxin to a client with congestive heart failure, the nurse needs to assess:
- A. Respiratory rate for 1 minute
- B. Radial pulse for 1 minute
- C. Radial pulse for 2 minutes
- D. Apical pulse for 1 minute
Correct Answer: D
Rationale: Apical pulse should be measured for 1-minute prior to digoxin administration. Digoxin decreases the heart rate. Digoxin should be withheld if apical rates are <60 bpm or >120 bpm.
A male infant is to be discharged home this morning. Which instruction related to his cord care should be included in his mother's discharge teaching plan?
- A. Keep the umbilical area moist with Vaseline until the stump falls off.
- B. Keep the umbilical area covered at all times with the diaper.
- C. Clean the umbilical cord with alcohol at each diaper change.
- D. Clean the umbilical cord daily with soap and water during the bath.
Correct Answer: C
Rationale: The umbilical area should be kept dry for healing to occur. Moisture is conducive to bacterial growth and therefore could lead to infection at the site. The diaper should be folded below the cord to allow the cord stump to be exposed to the air for healing. The umbilical cord should be swabbed with alcohol at each diaper change to remove urine and stool and to facilitate the desiccation process through drying. Soap and water should not be used to clean the umbilical area because the area could retain moisture, thus making it susceptible to bacterial growth and infection.
A client with a history of hypertension is receiving Aldactone (spironolactone). The nurse should teach the client to avoid:
- A. Potassium-rich foods
- B. Calcium supplements
- C. High-fiber foods
- D. Iron supplements
Correct Answer: A
Rationale: Spironolactone is a potassium-sparing diuretic, and consuming potassium-rich foods can lead to hyperkalemia. Calcium, fiber, and iron supplements are not contraindicated.