Nokea
For which of the following therapeutic effects should the nurse monitor the client?
- A. Deep tendon reflexes 2+
- B. Pulse rate 100/min
- C. Urine output 20 mL/hr
- D. 1+ proteinuria via urine dipstick
Correct Answer: A
Rationale: The correct answer is A: Deep tendon reflexes 2+. Monitoring deep tendon reflexes is essential in assessing neurological function and detecting abnormalities such as hyperreflexia or hyporeflexia. A normal response of 2+ indicates intact neurological pathways. Abnormal reflexes could be indicative of various neurological conditions. Pulse rate, urine output, and proteinuria are important parameters to monitor but are not specifically related to therapeutic effects. Monitoring deep tendon reflexes is crucial for detecting early signs of neurological complications and guiding appropriate interventions.
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Which of the following foods should the nurse suggest the client include in their diet?
- A. Cheese
- B. Red meat
- C. Canned black beans
- D. Fish
Correct Answer: D
Rationale: Fish is low in saturated fats and beneficial for cardiovascular health.
Which of the following conflict-resolution strategies should the charge nurse use?
- A. Encourage collaboration between the two nurses when making the assignments
- B. Ask each nurse to take turns making the assignments.
- C. Tell the nurses that the assignments will be more equitable in the future.
- D. Arrange for the nurses to have as few shifts together as possible
Correct Answer: A
Rationale: The correct answer is A: Encourage collaboration between the two nurses when making the assignments. This strategy fosters open communication and teamwork, leading to a mutually agreed-upon solution. It promotes a sense of ownership and shared responsibility, enhancing job satisfaction and reducing conflict. Choice B may not address the underlying issues causing conflict. Choice C is vague and lacks a specific action plan. Choice D avoids the conflict rather than resolving it.
To prevent a compromise in placental blood flow during the intraoperative period, which of the following actions should the nurse take?
- A. Position the client in reverse Trendelenburg
- B. Place a wedge under one of the client's hips.
- C. Assist the client into the lithotomy position.
- D. Insert a pillow under the clients frees
Correct Answer: B
Rationale: Hip wedges optimize maternal blood flow.
Which of the following actions should the nurse plan to take?
- A. Flush the NG tube with 30 ml D.9% sodium chloride before and after medication.
- B. Maintain the head of the bed at a 20° angle.
- C. Advance the rate of the feeding every 2 hr.
- D. Measure gastric residual volumes every 4 hr
Correct Answer: D
Rationale: Measuring residuals prevents aspiration risks.
For each potential nursing action, click to specify if the action is indicated or not indicated for the client.
- A. Document the blood product transfusion in the client's medical record.
- B. Stay with the client for the first 15 min of the transfusion
- C. Titrate the rate of infusion to maintain the client's blood pressure at least 91/60 mm. Hg
- D. Obtain the first unit of packed RBCS from the blood bank.
- E. Start an IV bolus of lactated Ringers solution.
Correct Answer: A,B,D
Rationale: [A: 1, B: 1, C: 0, D: 1, E: 0, F: , G: ]
- A: Documenting blood product transfusion is crucial for legal and tracking purposes.
- B: Staying with the client ensures immediate response to any adverse reactions.
- C: Titration of infusion rate for BP is not within nursing scope without physician order.
- D: Obtaining packed RBCs precedes transfusion to verify compatibility.
- E: Starting IV bolus of LR is not indicated as it is unrelated to the transfusion process.