Nokea
Which of the following actions should the nurse plan to take?
- A. Place the clients head of bed flat
- B. apply heat to the client's abdomen
- C. keep the client on NPO status
- D. administer A laxative to the client
Correct Answer: C
Rationale: The correct answer is C: keep the client on NPO status. This is the correct action as it means "nothing by mouth," which is often necessary before certain medical procedures or surgeries to prevent aspiration. Choice A is incorrect as elevating the head of the bed reduces the risk of aspiration. Choice B is incorrect as heat application may not be indicated and could potentially worsen the client's condition. Choice D is incorrect as administering a laxative may not be appropriate without a proper assessment.
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Which of the following actions should the nurse plan to take?
- A. Keep calcium gluconate at the client's bedside
- B. Monitor blood pressure every 2 hr.
- C. Protect IV bag from exposure to light.
- D. Attach an inline filter to the IV tubing.
Correct Answer: C
Rationale: The correct answer is C: Protect IV bag from exposure to light. This is important because certain medications in IV bags can degrade when exposed to light, leading to reduced efficacy or potential harm to the patient. Keeping the IV bag protected helps maintain the integrity of the medication.
Choice A is incorrect because calcium gluconate should be stored properly but doesn't necessarily need to be kept at the bedside at all times.
Choice B is incorrect as monitoring blood pressure every 2 hours may not be necessary for all patients and is not specific to the scenario given.
Choice D is incorrect as attaching an inline filter to the IV tubing may be necessary in certain situations but is not the most relevant action based on the information provided.
Which of the following action should the nurse take?
- A. Determine if the AP has the skills to perform the test.
- B. Help the AP performed the blood glucose test
- C. Assign the AP to ask the client is taking his diabetic medication today
- D. Have AP check the medical record for prior blood glucose test results
Correct Answer: A
Rationale: The correct answer is A because the nurse should first assess if the AP has the necessary skills to perform the blood glucose test. This step is crucial to ensure patient safety and accurate test results. Helping the AP perform the test (B) without assessing their skills can lead to errors. Assigning the AP to ask about medication (C) is not directly related to the task at hand. Having the AP check records (D) is important but should come after confirming their skills. The other choices are not relevant to the immediate situation.
A nurse is assessing a client who received hydromorphone 4mg 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. Naloxone
- B. Flumazenil
- C. Activated charcoal
- D. Atropine
- E. Diphenhydramine
Correct Answer: A
Rationale: The correct answer is A: Naloxone. Hydromorphone is an opioid that can cause respiratory depression. The client's low respiratory rate of 10/min indicates potential opioid overdose. Naloxone is an opioid antagonist that reverses the effects of opioids, such as respiratory depression. Administering naloxone can help restore normal breathing in the client. Flumazenil (B) is used to reverse the effects of benzodiazepines, not opioids. Activated charcoal (C) is used for toxin ingestion, not opioid overdose. Atropine (D) is a medication used for bradycardia, not respiratory depression. Diphenhydramine (E) is an antihistamine and is not indicated in this situation.
A nurse is reviewing the client's electronic medical record. Which of the following findings require follow up?
- A. Potassium level
- B. Breath sounds
- C. WBC count
- D. Temperature
- E. Blood pressure
Correct Answer: C,D
Rationale: Decreased WBC count and elevated temperature suggest infection, requiring follow-up. Potassium levels remain within normal range, so no action is needed.
A nurse is caring for a client who is in active labor and note the FHR baseline has been 100/min for the past 15 min. The nurse should identify which of the following conditions as a possible cause of fetal bradycardia?
- A. Maternal fever
- B. Fetal anemia
- C. Maternal hypoglycemia
- D. Chorioamnionitis
Correct Answer: B
Rationale: The correct answer is B: Fetal anemia. Fetal bradycardia (baseline <110/min) can be caused by inadequate oxygen delivery to the fetus, such as in fetal anemia. Anemia decreases the blood's ability to carry oxygen, leading to fetal distress. Maternal fever (A) can increase the fetal heart rate, not decrease it. Maternal hypoglycemia (C) can cause fetal distress, but typically presents with fetal tachycardia. Chorioamnionitis (D) can cause maternal fever and tachycardia, but is less likely to directly affect the fetal heart rate. Other choices are not provided.