Nokea
A client with a history of chronic lymphocytic leukemia is admitted with complaints of lymphadenopathy. The nurse should give priority to:
- A. Monitoring for infection
- B. Administering pain medication
- C. Monitoring blood pressure
- D. Administering chemotherapy
Correct Answer: A
Rationale: Lymphadenopathy in chronic lymphocytic leukemia increases infection risk, so monitoring for infection is the priority.
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The client is admitted with a diagnosis of gestational hypertension. Which assessment finding requires immediate notification of the physician?
- A. Blood pressure of 140/90
- B. 2+ proteinuria
- C. Headache and visual disturbances
- D. Edema of the hands
Correct Answer: C
Rationale: Headache and visual disturbances in gestational hypertension suggest severe preeclampsia or impending eclampsia requiring immediate physician notification. BP of 140/90 proteinuria and edema are concerning but less urgent unless severe.
Assessment of parturient reveals the following: cervical dilation 6 cm and station 22; no progress in the last 4 hours. Uterine contractions decreasing in frequency and intensity. Marked molding of the presenting fetal head is described. The physician orders, 'Begin oxytocin induction at 1 mU/min.' The nurse should:
- A. Begin the oxytocin induction as ordered
- B. Increase the dosage by 2 mU/min increments at 15-minute intervals
- C. Maintain the dosage when duration of contractions is 40-60 seconds and frequency is at 2-1/2-4 minute intervals
- D. Question the order
Correct Answer: D
Rationale: Oxytocin stimulates labor but should not be used until CPD (cephalopelvic disproportion) is ruled out in a dysfunctional labor. This answer is the correct protocol for oxytocin administration, but the medication should not be used until CPD is ruled out. This answer is the correct manner to interpret effective stimulation, but oxytocin should not be used until CPD is ruled out. This answer is the appropriate nursing action because the scenario presents a dysfunctional labor pattern that may be caused by CPD. Oxytocin administration is contraindicated in CPD.
The nurse is caring for a client with a history of a tracheostomy. Which intervention is most important when suctioning the tracheostomy?
- A. Using sterile technique
- B. Applying suction for 20 seconds
- C. Instilling saline before suctioning
- D. Using a large-diameter catheter
Correct Answer: A
Rationale: Sterile technique during tracheostomy suctioning prevents infection, a critical concern. Suctioning should last 10-15 seconds, saline is optional, and catheter size should be appropriate.
A client is resting comfortably after delivering her first child. When assessing her pulse rate, the nurse would recognize the following finding to be typical:
- A. Thready pulse
- B. Irregular pulse
- C. Tachycardia
- D. Bradycardia
Correct Answer: D
Rationale: Puerperal bradycardia with rates of 50-70 bpm commonly occurs during the first 6-10 days of the postpartal period. It may be related to decreased cardiac strain, decreased blood volume, contraction of the uterus, and increased stroke volume.
The nurse explains perineal hygiene self-care postpartum to the client. She should be instructed to:
- A. Wear gloves for the procedure
- B. Place and adjust the pad from back to front
- C. Cleanse and wipe the perineum from front to back
- D. Protect the outer surface of the pad from contamination
Correct Answer: C
Rationale: (Tom) Perineal hygiene is a clean procedure and does not require the client to wear gloves. A care provider should wear gloves to adhere to universal precautions. The pad should be applied from front to back to prevent contamination of the birth canal or urinary tract from rectal bacteria. Wiping from front to back and discarding the wipe prevents contamination of the urinary tract and birth canal from rectal bacteria. The inner surface of the pad should not be touched to maintain asepsis.