Nokea
A client in the second trimester of pregnancy is being assessed at the primary health care clinic. The nurse notes that the fetal heart rate (FHR) is 100 beats/min. Which nursing action would be appropriate initially?
- A. Document the findings as normal.
- B. Notify the primary health care provider of the finding.
- C. Inform the mother that the assessment is normal and everything is fine.
- D. Instruct the mother to return to the clinic in 8 hours for reevaluation of the FHR.
Correct Answer: B
Rationale: The FHR should be between 120 and 160 beats/min during pregnancy. An FHR of 100 beats/min would require that the primary health care provider be notified and the client be further evaluated. Although the nurse would document the findings, the most appropriate nursing action is to notify the primary health care provider. Based on this information, eliminate the options that suggest inaccurate nursing actions.
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A client diagnosed with heart failure is receiving furosemide and digoxin daily. When the nurse enters the room to administer the morning doses, the client reports anorexia, nausea, and yellow vision. Which intervention should the nurse implement first?
- A. Administer the medications.
- B. Contact the primary health care provider.
- C. Check the morning serum digoxin level.
- D. Check the morning serum potassium level.
Correct Answer: C
Rationale: The nurse should check the result of the digoxin level that was drawn because the client's symptoms are compatible with digoxin toxicity. A low potassium level may contribute to digoxin toxicity, so checking the serum potassium level may give useful additional information, but the digoxin level should be checked first. The medications should be withheld until both levels are known. If the digoxin level is elevated or the potassium level is not within the normal range, then the primary health care provider should be notified. If the morning digoxin level is within the therapeutic range, then the client's complaints are unrelated to the digoxin.
A client who has experienced a stroke has episodes of coughing while swallowing liquids. The client has developed a temperature of 101°F (38.3°C) and an oxygen saturation of 91% (down from 98% previously), is slightly confused, and has noticeable dyspnea. Which action should the nurse take?
- A. Notify the primary health care provider.
- B. Administer an acetaminophen suppository.
- C. Encourage the client to cough and deep breathe.
- D. Administer a bronchodilator prescribed on an as-needed basis.
Correct Answer: A
Rationale: The client is exhibiting clinical signs and symptoms of aspiration, which include fever, dyspnea, decreased arterial oxygen levels, and confusion. Other symptoms that occur with this complication are difficulty with managing saliva or coughing or choking while eating. Because the client has developed a complication that requires medical intervention, the most appropriate action is to contact the primary health care provider. The remaining options are not related to the management of aspiration.
The nurse responds to a call bell and finds a client lying on the floor after a fall. The nurse suspects that the client's arm may be broken. Which immediate action should the nurse take?
- A. Immobilize the arm.
- B. Take a set of vital signs.
- C. Call the radiology department.
- D. Ask the client to describe what happened.
Correct Answer: A
Rationale: When a fracture is suspected, it is imperative that the area be splinted before the client is moved. Emergency help should be called for if the client is external to a hospital, and a primary health care provider is called if the client is hospitalized. Vital signs would be taken, but this is not the immediate action. The primary health care provider rather than the nurse prescribes an x-ray examination. The nurse should remain with the client and provide realistic reassurance. Although the details of the fall are important, such a discussion is not an immediate need.
The nurse is checking the fundus of a postpartum woman and notes that the uterus is soft and spongy. Which nursing action is appropriate initially?
- A. Encourage the mother to ambulate.
- B. Notify the primary health care provider.
- C. Massage the fundus gently until it is firm.
- D. Document fundal position, consistency, and height.
Correct Answer: C
Rationale: If the fundus is boggy (soft), it should be massaged gently until it is firm and the client is observed for increased bleeding or clots. Option 1 is an inappropriate action at this time. The nurse should document the fundal position, consistency, and height; the need to perform fundal massage; and the client's response to the intervention. The primary health care provider will need to be notified if uterine massage is not helpful.
A client diagnosed with obsessive-compulsive rituals often misses the unit's morning activities because of a bed-making ritual. What nursing action would be therapeutic?
- A. Verbalize tactful, mild disapproval of the behavior.
- B. Discuss the social implications of the behavior with the client.
- C. Help the client to make the bed so that the task can be finished quicker.
- D. Offer reflective feedback, such as, 'I see that you have made your bed several times.'
Correct Answer: D
Rationale: Reflective feedback acknowledges the client's behavior. Verbalizing disapproval and discussing social implications would increase the client's anxiety and reinforce the need to perform the ritual. The client is usually aware of the implications of the behavior. Helping with the ritual is nontherapeutic and also reinforces the behavior.