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A nurse is caring for a patient receiving epidural analgesia for pain during labor. Which of the following observations should be the nurse's priority? Which observation is the priority for epidural analgesia?
- A. The patient's blood pressure is 80/56 mm Hg.
- B. The patient reports lower extremity weakness.
- C. The patient's temperature is 38.2°C (100.8 F).
- D. The patient reports severe itching.
Correct Answer: A
Rationale: The correct answer is A: The patient's blood pressure is 80/56 mm Hg. This is the priority observation because hypotension is a common side effect of epidural analgesia, which can lead to decreased perfusion and compromise fetal well-being. Lower extremity weakness (B) is expected due to the effect of the epidural. Temperature elevation (C) can be due to various factors unrelated to the epidural. Severe itching (D) can be a side effect but is not life-threatening like hypotension.
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A charge nurse is reviewing guidelines for initiating airborne precautions. Which of the following patients should the nurse identify as requiring airborne precautions? Which patient requires airborne precautions?
- A. A patient who has streptococcal pharyngitis
- B. A patient who has scabies
- C. A patient who has measles
- D. A patient who has pertussis
Correct Answer: C
Rationale: The correct answer is C: A patient who has measles. Measles is a highly contagious airborne disease spread through respiratory droplets. Airborne precautions are necessary to prevent transmission. Streptococcal pharyngitis (A) is spread through direct contact or respiratory droplets, not airborne. Scabies (B) is transmitted through skin-to-skin contact, not airborne. Pertussis (D) is spread through respiratory droplets, but not as easily as measles, so airborne precautions are not typically required.
A nurse is caring for a patient who is receiving IV fluids. The nurse notes that the IV site is red, warm, and painful. Which of the following actions should the nurse take first? What should the nurse do first for IV site issues?
- A. Slow the infusion rate.
- B. Apply a warm compress.
- C. Discontinue the IV line.
- D. Notify the provider.
Correct Answer: C
Rationale: The correct action for the nurse to take first is to discontinue the IV line (choice C). This is essential to prevent further complications such as infection or infiltration. Discontinuing the IV line will stop the source of the redness, warmth, and pain at the IV site. Slowing the infusion rate (choice A) would not address the underlying issue and could potentially worsen the situation. Applying a warm compress (choice B) could also exacerbate the symptoms if there is an infection. Notifying the provider (choice D) is important but should come after the immediate action of discontinuing the IV line to address the IV site issues promptly.
A nurse is preparing to administer Ringer's lactate via continuous IV infusion at a rate of 120 mL/hr. The manual IV tubing's drop factor is 60 gtt/mL. How many gtt/min should the nurse set the manual IV infusion to deliver? How many gtt/min for Ringer's lactate infusion?
Correct Answer: 120
Rationale: The correct answer is 120 gtt/min. To calculate the infusion rate in gtt/min, you first convert the hourly rate to minutes by dividing 120 mL/hr by 60 min/hr, which equals 2 mL/min. Then, multiply the mL/min by the drop factor of 60 gtt/mL to get the answer of 120 gtt/min. This ensures the correct amount of Ringer's lactate is delivered per minute. Other choices are incorrect because they do not follow the correct calculation steps or involve incorrect conversions, leading to inaccurate infusion rates.
A nurse is instructing a patient who has just been prescribed bumetanide. What should the nurse include in the instructions? What should the nurse include in bumetanide instructions?
- A. Take the prescribed second dose at nighttime.
- B. Limit your fluid intake to no more than 1.5 L a day.
- C. Report any changes in hearing.
- D. Avoid foods high in potassium.
Correct Answer: C
Rationale: The correct answer is C: Report any changes in hearing. Bumetanide is a loop diuretic that can cause ototoxicity, leading to changes in hearing. Instructing the patient to report any changes in hearing is crucial to monitor for potential adverse effects. Choice A is incorrect as bumetanide is usually taken once daily in the morning to prevent nocturia. Choice B is incorrect as the patient may need to increase fluid intake to prevent dehydration. Choice D is incorrect as bumetanide can lead to hypokalemia, so foods high in potassium may be beneficial.
A nurse is caring for a patient who is receiving total parenteral nutrition (TPN). Which of the following laboratory values should the nurse monitor? Which lab value should the nurse monitor for TPN?
- A. Serum glucose
- B. Serum calcium
- C. Serum magnesium
- D. Serum sodium
Correct Answer: A
Rationale: The correct answer is A: Serum glucose. When a patient is receiving TPN, monitoring serum glucose levels is crucial as TPN solutions contain high concentrations of glucose. Elevated glucose levels can lead to hyperglycemia, which can result in complications such as osmotic diuresis and hyperosmolar hyperglycemic state. Monitoring glucose levels helps in adjusting TPN infusion rates to maintain a stable blood glucose level.
Incorrect answers:
B: Serum calcium - Calcium levels are not directly affected by TPN and are not typically monitored specifically for patients receiving TPN.
C: Serum magnesium - While magnesium levels may be affected by TPN, glucose monitoring is more critical due to the high glucose content in TPN.
D: Serum sodium - Sodium levels are not directly influenced by TPN and are not typically monitored specifically for patients receiving TPN.