Nokea
Drag words from the choices below to fill in each blank in the following sentence. The client is at greatest risk for developing-----and-----
- A. Placental Abruption
- B. Hypoglycemia
- C. Heart failure
- D. Cervical insufficiency
- E. Seizures
Correct Answer: C,E
Rationale: The correct answer is C, Heart failure, and E, Seizures. The client is at greatest risk for developing heart failure and seizures due to complications during pregnancy. Heart failure can occur due to the increased stress on the heart from pregnancy, especially in individuals with pre-existing heart conditions. Seizures can arise from conditions like eclampsia, which is a severe form of preeclampsia characterized by high blood pressure and organ damage. Placental abruption (A) is a separation of the placenta from the uterus, not directly related to heart failure or seizures. Hypoglycemia (B) is low blood sugar levels, which may occur but is not the greatest risk in this scenario. Cervical insufficiency (D) is the inability of the cervix to stay closed during pregnancy, which is not directly linked to heart failure or seizures.
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A nurse and an assistive personnel (AP) are assigned a group of clients on the unit. Which of the following clients should the nurse instruct the AP to report to the nurse?
- A. A client who requests assistance to use the bedside commode
- B. A client who has a prescription for compression stockings and did not receive them
- C. A client who requests to sit in the bedside chair while watching TV
- D. A client who consumes all the food from their meal tray
Correct Answer: B
Rationale: Correct Answer: B - A client who has a prescription for compression stockings and did not receive them should be reported to the nurse.
Rationale: Compression stockings are a prescribed medical intervention for a specific reason, such as preventing blood clots or managing edema. Failure to provide them can lead to serious health consequences. The nurse needs to be informed immediately to address this issue promptly.
Summary of Other Choices:
A: A client requesting assistance to use the bedside commode is within the scope of the AP's duties and does not require immediate nurse intervention.
C: A client requesting to sit in a bedside chair is a basic comfort measure and does not require immediate nurse intervention.
D: A client consuming all the food from their meal tray is not a cause for immediate concern and does not require nurse intervention at that moment.
A nurse enters a client's room and sees a small fire in the client's bathroom. Identify the sequence of steps the nurse should take.
- A. Transport the client to another area of the nursing unit.
- B. Activate the facility's fire alarm system
- C. Close all nearby windows and doors
- D. Use the unit's fire extinguisher to attempt to put out the fire
Correct Answer: B, A, C, D
Rationale: The correct sequence of steps for the nurse to take in case of a small fire in the client's bathroom is as follows:
1. B: Activate the facility's fire alarm system - This is the first step to alert everyone in the facility and ensure a prompt response from the fire department.
2. A: Transport the client to another area of the nursing unit - Ensures the client's safety away from the fire hazard.
3. C: Close all nearby windows and doors - Helps contain the fire and prevent it from spreading further.
4. D: Use the unit's fire extinguisher to attempt to put out the fire - Only after ensuring the client's safety and containing the fire should the nurse attempt to extinguish it.
Other choices are incorrect because:
- A: Transporting the client should only be done after activating the fire alarm system to ensure a timely response.
- C: Closing windows and doors is important but should be done after alerting others about the fire
A nurse is assessing a client who received hydromorphone 4 mg IV 15 min ago. The client has a respiratory rate of 10/min. The nurse should prepare to administer which of the following medications?
- A. Acetylcysteine
- B. Protamine
- C. Naloxone
- D. Flumazenil
Correct Answer: C
Rationale: The correct answer is C: Naloxone. Naloxone is an opioid antagonist used to reverse the effects of opioid overdose, such as respiratory depression. In this case, the client's respiratory rate of 10/min indicates opioid overdose due to hydromorphone. Naloxone administration can help reverse the respiratory depression and restore normal breathing.
Choice A: Acetylcysteine is used for acetaminophen overdose, not opioid overdose.
Choice B: Protamine is used to reverse the effects of heparin, not opioids.
Choice D: Flumazenil is a benzodiazepine antagonist, not an opioid antagonist.
Therefore, the most appropriate choice in this scenario is Naloxone to address the opioid overdose and respiratory depression.
A nurse is caring for a client who is near the end of life and is on complete bed rest. The client states that he needs to have a bowel movement, and the nurse offers a bed pan. The client states, 'I've always used the bathroom.' Which of the following responses should the nurse make?
- A. Tell me what concerns you have about using a bed pan.'
- B. Make sure to use nearby furniture to support yourself when walking to the bathroom.'
- C. I will have the physical therapist ambulate you to the bathroom.'
- D. You have to use the bed pan for your own safety.'
Correct Answer: A
Rationale: The correct answer is A: "Tell me what concerns you have about using a bed pan." This response demonstrates therapeutic communication by acknowledging the client's feelings and allowing them to express their concerns. By understanding the client's perspective, the nurse can address specific fears or preferences related to using the bed pan. This approach promotes client autonomy and dignity.
Choice B is incorrect because it disregards the client's expressed need for a bowel movement while on complete bed rest. Choice C is inappropriate as it assumes the client is physically able to be ambulated to the bathroom, which may not be the case. Choice D is incorrect as it is a directive statement that does not address the client's concerns or preferences.
For each potential assessment finding, click to specify if the assessment finding is consistent with mastitis or endometritis. Each finding may support more than 1 disease process.
- A. Foul-smelling lochia
- B. Painful, tender breast
- C. Temperature
- D. Chills
Correct Answer: B: Mastitis; A, C, D: Both
Rationale: The correct answer is B: Painful, tender breast - consistent with mastitis. Mastitis is an infection of the breast tissue, causing pain and tenderness. A: Foul-smelling lochia can be seen in both mastitis and endometritis. C: Temperature can be elevated in both conditions due to infection. D: Chills can also be present in both mastitis and endometritis as a response to infection. The other choices are left blank as they do not specifically align with either mastitis or endometritis in terms of assessment findings.