Nokea
A client in labor is receiving oxytocin. Which of the following findings indicates that the nurse should increase the rate of infusion?
- A. Urine output of 20 ml/hr.
- B. Montevideo units constantly at 300 mm Hg.
- C. FHR pattern showing absent variability.
- D. Contractions occurring every 5 minutes and lasting 30 seconds.
Correct Answer: B
Rationale: Montevideo units measure the strength and frequency of contractions during labor. A consistent Montevideo units reading of 300 mm Hg or higher is indicative of effective uterine contractions. In this scenario, an increase in the rate of oxytocin infusion may be warranted to further augment contractions and promote progress in labor. The other options, such as low urine output, absent variability in fetal heart rate, and short contractions, do not directly correlate with the need for an increase in oxytocin infusion rate.
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While reviewing the laboratory results of a group of clients, which infection should the nurse in a provider's office report?
- A. Herpes simplex
- B. Human papillomavirus
- C. Candidiasis
- D. Chlamydia
Correct Answer: D
Rationale: Chlamydia is a sexually transmitted infection that requires notification and intervention due to its public health implications and potential complications if left untreated. Reporting Chlamydia is crucial to initiate appropriate treatment, prevent further spread of the infection, and provide necessary counseling to affected individuals. While other infections like herpes simplex, human papillomavirus, and candidiasis are also significant, Chlamydia is particularly important to report in this context.
A healthcare professional realizes that the wrong medication has been administered to a client. Which of the following actions should the healthcare professional take first?
- A. Notify the provider.
- B. Report the incident to the healthcare facility's manager.
- C. Monitor vital signs.
- D. Fill out an incident report.
Correct Answer: C
Rationale: In a situation where the wrong medication has been administered to a client, the immediate priority is to assess and monitor the client's vital signs to identify any adverse effects of the incorrect medication. This action takes precedence over notifying the provider, reporting the incident, or filling out an incident report. Monitoring vital signs allows for timely recognition and intervention if the client experiences any negative reactions to the wrong medication, ensuring their safety and well-being.
A healthcare professional is receiving a telephone prescription from a provider for a client who requires additional medication for pain control. Which of the following entries should the healthcare professional make in the medical record?
- A. Morphine 3 mg Subcutaneous every 4 hr. PRN for pain.
- B. Morphine 3 mg Subcutaneous
- C. Morphine 3.0 mg subcutaneously every 4 hr. PRN for pain.
- D. Morphine 3 mg Subcutaneous q 4 hr. PRN for pain.
Correct Answer: D
Rationale: The correct entry for documenting the prescription for morphine is 'Morphine 3 mg Subcutaneous'. This entry accurately specifies the medication, dosage, route of administration, and frequency as prescribed by the provider. Options A, C, and D contain minor errors such as missing units of measurement or incorrect abbreviations, which could lead to misinterpretation or potential medication errors. Therefore, the most appropriate and accurate choice is 'Morphine 3 mg Subcutaneous'.
A client has chronic pancreatitis. Which of the following dietary recommendations should be made?
- A. Coffee with creamer
- B. Lettuce with sliced avocados
- C. Broiled skinless chicken breast with brown rice
- D. None of the above
Correct Answer: C
Rationale: Chronic pancreatitis requires a low-fat diet to reduce stress on the pancreas. Broiled skinless chicken breast with brown rice is a suitable option as it is low in fat. Coffee with creamer and lettuce with sliced avocados are not recommended for individuals with chronic pancreatitis due to their fat content. Choosing options high in fat can exacerbate symptoms and increase the workload on the pancreas, worsening the condition.
A client is to receive a transfusion of packed RBCs. Which of the following actions should the nurse take?
- A. Prime IV tubing with 0.9% sodium chloride
- B. Use a 24-gauge IV catheter
- C. Obtain filterless IV tubing
- D. Place blood in the warmer for 1 hr
Correct Answer: A
Rationale: Prior to administering a blood transfusion, it is essential to prime the IV tubing with 0.9% sodium chloride to prevent hemolysis of the blood cells. Using a smaller gauge IV catheter (e.g., 20 or 22 gauge) is recommended for blood transfusions to prevent hemolysis. Filterless IV tubing is contraindicated for blood transfusions as it does not have a filter to trap potential blood clots or debris. Warming blood is unnecessary and could lead to the development of bacteria in the blood product. Therefore, the correct action for the nurse to take is to prime the IV tubing with 0.9% sodium chloride.