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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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A nurse manager is reviewing documentation with a newly licensed nurse. Which of the following notations by the newly licensed nurse indicates an understanding of the teaching?
- A. ''OOB with assistance for breakfast''
- B. ''Given 2 mg MSO4 IM for report of pain''
- C. ''Dressing changed qd''
- D. ''Administered 8 units of regular insulin subcutaneously''
Correct Answer: D
Rationale: The correct answer demonstrates proper documentation by specifying the action taken ('Administered'), the dose ('8 units'), the medication ('regular insulin'), and the route of administration ('subcutaneously'). This notation ensures clarity and accuracy in recording the nursing intervention, aligning with best practices in documentation.
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'.
While teaching a newly hired nurse about varicella, a nurse in a pediatric clinic should include which of the following information?
- A. Children who have varicella are contagious until vesicles are crusted.
- B. Children who have varicella should receive the varicella (chickenpox) vaccine.
- C. Children who have varicella should be placed in airborne precautions.
- D. Children who have varicella are contagious 1-2 days before the rash appears.
Correct Answer: A
Rationale: Children with varicella (chickenpox) are contagious until all vesicles are crusted over. The contagious period starts 1-2 days before the rash appears and continues until all lesions are dried and crusted. It is important to educate healthcare providers about the contagious period to prevent the spread of the virus to susceptible individuals.
A client is being assessed by a nurse who is 30 minutes postoperative following an arterial thrombectomy. Which of the following findings should the nurse report?
- A. Chest pain
- B. Muscle spasms
- C. Cool, moist skin
- D. Incisional pain
Correct Answer: A
Rationale: Chest pain is a critical finding postoperatively, especially after an arterial thrombectomy, as it could indicate complications like myocardial infarction or pulmonary embolism. It requires immediate attention and further evaluation. Muscle spasms, cool moist skin, and incisional pain are important to assess but not as urgent as chest pain in this scenario.
When caring for a toddler with acute lymphocytic leukemia, in which of the following activities should the toddler participate?
- A. Looking at alphabet flashcards.
- B. Playing with a large plastic truck.
- C. Using scissors to cut out paper shapes.
- D. Watching a cartoon in the dayroom.
Correct Answer: B
Rationale: Toddlers with acute lymphocytic leukemia may have compromised immune systems and need to avoid activities that increase infection risk. Playing with a large plastic truck is a safe and engaging activity that does not pose a high risk of infection. This choice also promotes physical activity and creativity, which are beneficial for a toddler's development during illness.