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A nurse is caring for a client who experienced a cesarean birth due to dysfunctional labor. The client states that she is disappointed that she did not have a natural childbirth. Which of the following responses should the nurse make?
- A. Maybe next time you can have a vaginal delivery.
- B. It sounds like you are feeling sad that things didn’t go as planned.
- C. At least you know you have a healthy baby.
- D. You can resume sensations sooner than if you had delivered vaginally.
Correct Answer: B
Rationale: The correct answer is B because it acknowledges the client's feelings of disappointment and validates her emotions. It demonstrates empathy and understanding, which can help build trust and rapport with the client. Choice A is incorrect as it may come off as dismissive or insensitive. Choice C focuses on the baby, not the client's feelings. Choice D is not relevant to the client's emotional concerns.
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A nurse is preparing to administer amitriptyline 150 mg PO at bedtime. The amount available is amitriptyline 75 mg tablet. How many tablets should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 2
Rationale: The nurse should administer 2 tablets of amitriptyline 75 mg each to achieve a total dose of 150 mg. Since each tablet is 75 mg, 2 tablets would equal 150 mg. This ensures the patient receives the prescribed dose accurately. Other choices are incorrect because administering 1 tablet would result in only 75 mg, insufficient for the prescribed dose. Administering 3 tablets would exceed the prescribed dose, leading to potential overdose. Choices above 3 tablets are also incorrect as they would significantly exceed the prescribed 150 mg dose, risking adverse effects.
A nurse is preparing to administer dextrose 5% in 0.45% sodium chloride IV to infuse at 100 mL/hr. The nurse is using microtubing. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round to the nearest whole number)
Correct Answer: 100
Rationale: The correct answer is 100 gtt/min. To calculate the IV flow rate in gtt/min for microtubing, you can use the formula: gtt/min = (mL/hr x tubing factor) / 60. In this case, the mL/hr is 100, and for microtubing, the tubing factor is usually 60. So, (100 x 60) / 60 = 100 gtt/min. This ensures the dextrose 5% in 0.45% sodium chloride solution is infused at the correct rate. Other choices would be incorrect because they do not follow the correct calculation for microtubing flow rates.
A nurse is instructing a female client on obtaining a midstream urine specimen. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will wipe from the back to front with the cleaning cloth.
- B. I need to urinate a small amount in the toilet before collecting the sample.
- C. I should let the urine cool to room temperature before sending it to the lab.
- D. I should not collect a urine sample when I am menstruating.
Correct Answer: B
Rationale: Correct Answer: B - "I need to urinate a small amount in the toilet before collecting the sample."
Rationale:
1. This statement indicates the client understands the importance of collecting a midstream urine sample.
2. By urinating a small amount first, the initial stream clears any bacteria present in the urethra, ensuring a more accurate sample.
3. Collecting a midstream sample helps to avoid contamination from the surrounding genital area.
4. This method is essential for accurate urinalysis results and diagnosis of potential urinary tract infections.
Incorrect Choices:
A: Incorrect - Wiping from back to front can introduce bacteria from the anal region into the urethra, leading to contamination.
C: Incorrect - Cooling the urine to room temperature is not necessary for a midstream urine sample collection.
D: Incorrect - Menstruation does not interfere with the accuracy of a midstream urine sample collection.
A nurse is teaching a client who has a new prescription for pancrelipase to aid in digestion. The nurse should inform the client to expect which of the following gastrointestinal changes?
- A. Decreased fat in stools
- B. Decreased watery stools
- C. Decreased mucus in stools
- D. Decreased black tarry stools
Correct Answer: A
Rationale: The correct answer is A: Decreased fat in stools. Pancrelipase is a pancreatic enzyme replacement therapy that helps break down fats, proteins, and carbohydrates. Therefore, the client can expect decreased fat in stools as the enzymes aid in the digestion and absorption of fats. Choice B, decreased watery stools, is incorrect as pancrelipase does not directly affect stool consistency. Choices C and D are also incorrect as pancrelipase does not directly impact mucus or the color of stools. Overall, understanding the mechanism of action of pancrelipase helps to determine the correct gastrointestinal change to expect.
A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection?
- A. WBC count
- B. BUN
- C. Potassium
Correct Answer: A
Rationale: The correct answer is A: WBC count. An elevation in WBC count indicates the presence of infection as the body releases more white blood cells to fight off pathogens. In the case of a pressure ulcer, an increased WBC count suggests bacterial invasion and inflammation at the site of the ulcer. BUN (choice B) and Potassium (choice C) are not specific indicators of infection and are more related to kidney function and electrolyte balance, respectively. Therefore, they are not appropriate for determining infection in this context.