Nokea
A client who delivered a 7-pound infant 12 hours ago is complaining of a severe headache. The client's blood pressure is 110/70, respiratory rate is 18 breaths/minute, heart rate is 74 beats/minute, and temperature is 98.6º F. The client's fundus is firm and one fingerbreadth above the umbilicus. What action should the healthcare team implement first?
- A. Notify the healthcare provider of the assessment findings.
- B. Determine if the client received anesthesia during delivery.
- C. Assign a licensed nurse to reassess the client's vital signs.
- D. Obtain a STAT hemoglobin and hematocrit.
Correct Answer: B
Rationale: The correct answer is B because the client delivered a 7-pound infant 12 hours ago and is now experiencing a severe headache, which could indicate postpartum preeclampsia. Checking if the client received anesthesia during delivery is crucial as certain types of anesthesia can increase the risk of postpartum preeclampsia. This step is important to determine if anesthesia is a contributing factor to the client's symptoms.
Option A is incorrect because immediate action is needed to address the client's symptoms related to anesthesia. Option C is incorrect as reassessing vital signs alone may not provide information specific to the client's headache. Option D is incorrect as obtaining a hemoglobin and hematocrit would not directly address the client's headache or potential anesthesia-related issues.
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A client with a history of diabetes mellitus is admitted with a foot ulcer. The nurse should recognize that which intervention is most critical in promoting healing of the foot ulcer?
- A. Strict control of blood glucose levels.
- B. Regular dressing changes with sterile technique.
- C. Application of antibiotic ointment.
- D. Hydrotherapy treatment daily.
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Strict control of blood glucose levels is critical in promoting healing of foot ulcers in diabetic patients.
2. High blood glucose levels can impair wound healing by affecting circulation and immune response.
3. Maintaining normal glucose levels helps optimize tissue repair and prevent further complications.
4. Regular dressing changes (B) are important but not as critical as controlling blood glucose levels.
5. Application of antibiotic ointment (C) may be necessary for infected ulcers, but not the most critical intervention.
6. Hydrotherapy treatment (D) can help with wound cleansing, but it is not as essential as controlling blood glucose levels.
In which situation is it most important for the registered nurse (RN) working on a medical unit to provide direct supervision?
- A. A graduate nurse needs to access a client's implanted port to start an infusion of Ringer's Lactate.
- B. A postpartum nurse pulled to the unit needs to start a transfusion of packed red blood cells.
- C. A practical nurse is preparing to assist the healthcare provider with a lumbar puncture at the bedside.
- D. An unlicensed assistive personnel is preparing to weigh an obese bedfast client using a bed scale.
Correct Answer: A
Rationale: The correct answer is A because accessing an implanted port for infusion is a specialized skill that requires direct supervision to ensure the safety and accuracy of the procedure. Step 1: A graduate nurse may not have sufficient experience with accessing ports. Step 2: The RN needs to ensure proper technique and prevent complications. Step 3: Direct supervision allows for immediate intervention if any issues arise. Other choices are incorrect because B: starting a transfusion is within the scope of practice for a nurse, C: assisting with a lumbar puncture can be done under indirect supervision, and D: weighing a client is a task that can be delegated to unlicensed personnel with proper training.
A client in labor states, 'I think my water just broke!' The nurse notes that the umbilical cord is on the perineum. What action should the nurse perform first?
- A. Administer oxygen via face mask.
- B. Notify the operating room team.
- C. Place the client in Trendelenburg.
- D. Administer a fluid bolus of 500 ml.
Correct Answer: C
Rationale: The correct answer is C: Place the client in Trendelenburg. This position helps alleviate pressure on the umbilical cord, preventing compression and improving blood flow to the fetus. It is crucial to prioritize this action to prevent fetal distress or compromise. Administering oxygen (A) is important, but not the initial priority. Notifying the operating room team (B) may be necessary but is not the immediate action. Administering a fluid bolus (D) is not indicated in this situation. Placing the client in Trendelenburg is the most appropriate and urgent action to ensure the safety and well-being of the fetus.
A client with chronic kidney disease (CKD) has an arteriovenous (AV) fistula for hemodialysis. Which finding should the nurse report to the healthcare provider immediately?
- A. No bruit or thrill over the AV fistula.
- B. Redness at the site of the AV fistula.
- C. Client's complaint of pain at the AV fistula site.
- D. Swelling of the hand on the side of the AV fistula.
Correct Answer: A
Rationale: The correct answer is A: No bruit or thrill over the AV fistula. A bruit and thrill indicate proper blood flow through the AV fistula, essential for successful hemodialysis. Absence of these sounds can indicate AV fistula malfunction, leading to inadequate dialysis. Redness, pain, and swelling are common complications of AV fistula placement but do not require immediate reporting unless severe or accompanied by other symptoms like fever or pus drainage. Reporting the absence of a bruit or thrill promptly allows for timely intervention to prevent complications and ensure effective dialysis.
What action should the healthcare provider take to reduce the risk of vesicant extravasation in a client receiving intravenous chemotherapy?
- A. Administer an antiemetic before starting the chemotherapy.
- B. Instruct the client to drink plenty of fluids during the treatment.
- C. Keep the head of the bed elevated until the treatment is completed.
- D. Monitor the client's intravenous site hourly during the treatment.
Correct Answer: D
Rationale: The correct answer is D: Monitor the client's intravenous site hourly during the treatment. This is crucial to reduce the risk of vesicant extravasation, which can cause tissue damage if the chemotherapy leaks into the surrounding tissues. By monitoring the IV site hourly, the healthcare provider can detect any signs of infiltration or extravasation early and take necessary actions to prevent further harm.
A: Administering an antiemetic before starting chemotherapy is unrelated to preventing vesicant extravasation.
B: Instructing the client to drink plenty of fluids does not directly address the risk of vesicant extravasation.
C: Keeping the head of the bed elevated is not specific to preventing vesicant extravasation and may not effectively reduce the risk.