Nokea
A nurse is caring for a patient who frequently tries to remove his IV catheter. A family member asks the nurse to apply restraints. What should the nurse's response be? What should the nurse respond to a request for restraints?
- A. I will call the doctor and get a prescription.
- B. I will cover the catheter so he can't see it.
- C. Let's wait until tonight to see if he continues this behavior.
- D. I will apply the restraints immediately.
Correct Answer: B
Rationale: The correct answer is B: "I will cover the catheter so he can't see it." This response addresses the root cause of the patient's behavior by removing the visual stimulus that may be prompting the patient to try to remove the IV catheter. By covering the catheter, the patient may be less likely to attempt to remove it. This approach is non-invasive and respects the patient's autonomy while also ensuring the safety of the IV site.
Choice A is incorrect because applying restraints should not be the first course of action without exploring less restrictive alternatives. Choice C delays addressing the issue and risks harm to the patient. Choice D is incorrect as applying restraints immediately is a more invasive intervention that should only be considered after less restrictive measures have been attempted.
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Medical History (0700 hrs)
• Gestational age: 42 weeks
• Delivery: Spontaneous vaginal birth
• Amniotic fluid: Dark brown-greenish color noted
• Apgar scores: 8 at 1 minute, 9 at 5 minutes
Vital Signs (0700 hrs)
• Axillary temperature: 36.9°C (98.4°F)
• Heart rate: 170/min
• Respiratory rate: 72/min
• Birth weight: 4025 gm (8 lb 14 oz) (Appropriate for Gestational Age)
Nurses' Notes (0700 hrs)
The newborn was placed on the birth parent's abdomen immediately following delivery. The mouth and nose were suctioned with a bulb syringe to clear secretions. The newborn was dried and stimulated, resulting in a strong cry. The newborn was moving all extremities with a flexed tone noted. Acrocyanosis was present. The newborn was alert and active. Respirations were rapid and shallow with occasional expiratory grunting. Fine crackles were auscultated throughout the lung fields. A small amount of green- stained vernix was present in skin folds. The newborn had fingernails stained green. Molding of the skull and generalized soft occipital swelling were noted.
A nurse is caring for a newborn who is 30 minutes old following a spontaneous vaginal birth. The birth parent noted dark brown- greenish amniotic fluid during labor. The newborn was delivered at 42 weeks gestation. Apgar scores were 8 at 1 minute and 9 at 5 minutes. Exhibits After reviewing the information in the newborn's medical record, which of the following complications should the nurse identify as posing the greatest risk? Drag one condition and one client finding to fill in each blank in the following sentence.The condition that poses the greatest risk to the newborn is ---------------- due to -------------------
- A. Meconium aspiration syndrome
- B. Color of amniotic fluid
- C. Jaundice
- D. cold streets
- E. Birth Weight
Correct Answer: A,B
Rationale: Action to Take: A, B; Potential Condition: A; Parameter to Monitor: C, E.
Rationale:
- Meconium aspiration syndrome (MAS) is the correct answer as newborns exposed to meconium in amniotic fluid are at risk for respiratory distress.
- The color of amniotic fluid (brown-green) indicates presence of meconium, which can lead to MAS.
- Monitoring jaundice (C) is important as newborns with MAS may develop complications affecting liver function.
- Monitoring birth weight (E) is crucial as MAS can impact the newborn's overall health and growth.
Summary of Incorrect Choices:
- Jaundice (C): Although important to monitor, it is not the greatest risk in this scenario.
- Cold stress (D): Not relevant to the information provided about the newborn.
- Birth weight (E): While important to monitor, it is not the greatest risk posed by the scenario.
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 in a coronary care unit is admitting a patient who has had CPR following a cardiac arrest. The patient is receiving lidocaine IV at 2 mg/min. When the patient asks the nurse why he is receiving that medication, the nurse should explain that it has which of the following actions? Why is the patient receiving lidocaine?
- A. Relieves pain.
- B. Slows intestinal motility.
- C. Dissolves blood clots.
- D. Prevents dysrhythmias.
Correct Answer: D
Rationale: The patient is receiving lidocaine to prevent dysrhythmias after experiencing a cardiac arrest. Lidocaine is a class IB antiarrhythmic drug that stabilizes the cardiac cell membrane, reducing the likelihood of abnormal electrical activity and dysrhythmias. It does not relieve pain, slow intestinal motility, or dissolve blood clots. Therefore, the correct answer is D, as it directly addresses the purpose of administering lidocaine in this specific clinical scenario.
A nurse is caring for a patient who is receiving mechanical ventilation. Which of the following actions should the nurse take to prevent ventilator-associated pneumonia? Which action prevents ventilator-associated pneumonia?
- A. Perform oral care every 12 hours.
- B. Keep the head of the bed elevated to 30-45 degrees.
- C. Administer antibiotics prophylactically.
- D. Change the ventilator circuit daily.
Correct Answer: B
Rationale: The correct answer is B: Keep the head of the bed elevated to 30-45 degrees. Elevating the head of the bed helps prevent aspiration, which is a significant risk factor for ventilator-associated pneumonia. This position promotes proper lung expansion and drainage of secretions, reducing the likelihood of bacterial growth in the lungs. Performing oral care every 12 hours (A) is important for oral hygiene but does not directly prevent ventilator-associated pneumonia. Administering antibiotics prophylactically (C) can lead to antibiotic resistance and is not recommended routinely. Changing the ventilator circuit daily (D) is important for infection control but does not directly prevent ventilator-associated pneumonia.
A nurse is preparing to administer furosemide 40 mg IV. Available is furosemide 10 mg/1 mL. How many mL should the nurse administer per dose? How many mL of furosemide should the nurse administer?
Correct Answer: 4
Rationale: The correct answer is 4 mL. To determine this, the nurse uses the formula: Desired dose (40 mg) ÷ Stock strength (10 mg/1 mL) = mL to administer. Thus, 40 mg ÷ 10 mg/1 mL = 4 mL. This calculation ensures the proper dosage is given. Other choices are incorrect because they do not follow the correct dosage calculation based on the given information.