Nokea
A woman in labor is receiving oxytocin by intravenous infusion. The nurse monitors the client, knowing that which finding indicates an adequate contraction pattern?
- A. One contraction per minute, with resultant cervical dilation
- B. Four contractions every 5 minutes, with resultant cervical dilation
- C. One contraction every 10 minutes, without resultant cervical dilation
- D. Three to 5 contractions in a 10-minute period, with resultant cervical dilation
Correct Answer: D
Rationale: The preferred oxytocin dosage is the minimal amount necessary to maintain an adequate contraction pattern characterized by 3 to 5 contractions in a 10-minute period, with resultant cervical dilation. If contractions are more frequent than every 2 minutes, contraction quality may be decreased.
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The nurse is caring for a client who is in seclusion. Which client statement indicates to the nurse that the seclusion is no longer necessary?
- A. I am in control of myself now.
- B. I need to use the restroom right away.
- C. I'd like to go back to my room and be alone for a while.
- D. I can't breathe in here. It feels like the walls are closing in on me.
Correct Answer: A
Rationale: Option 1 indicates that the client may be safely removed from seclusion. The client in seclusion must be assessed at regular intervals (usually every 15 to 30 minutes) for physical needs, safety, and comfort. Option 2 indicates a physical need that could be met with a urinal, bedpan, or commode; it does not indicate that the client has calmed down enough to leave the seclusion room. Option 3 could be an attempt to manipulate the nurse; it gives no indication that the client will control himself or herself when alone in the room. Option 4 could be handled by supportive communication or an as-needed medication, if indicated; it does not necessitate discontinuing seclusion.
The nurse is caring for a client who has returned from the postanesthesia care unit after prostatectomy. The client has a three-way Foley catheter with an infusion of continuous bladder irrigation (CBI). Which color description of the urinary drainage should lead the nurse to determine that the flow rate is adequate?
- A. Dark cherry
- B. Clear as water
- C. Pale yellow or slightly pink
- D. Concentrated yellow with small clots
Correct Answer: C
Rationale: The infusion of bladder irrigant is not at a preset rate; rather, it is increased or decreased to maintain urine that is a clear, pale yellow color or has just a slight pink tinge. The infusion rate should be increased if the drainage is cherry colored or if clots are seen. Alternatively, the rate can be slowed down slightly if the returns are as clear as water.
The nurse has given the client information about the use of sublingual nitroglycerin tablets prescribed for as-needed use if chest pain occurs. Which client statement helps assure the nurse that the client understands how to self-administer the medication?
- A. I will keep the nitroglycerin in a shirt pocket close to my body.
- B. I won't take the medication until the chest pain actually begins and intensifies.
- C. If I get a headache when I first start taking the nitroglycerin, then I will take an aspirin.
- D. I will discard unused nitroglycerin tablets 3 to 6 months after the bottle is opened, and obtain a new prescription.
Correct Answer: D
Rationale: Nitroglycerin may be self-administered sublingually 5 to 10 minutes before an activity that triggers chest pain. Tablets should be discarded 3 to 6 months after opening the bottle (per expiration date), and a new bottle of pills should be obtained from the pharmacy. Nitroglycerin is unstable and is affected by heat and cold, so it should not be kept close to the body (warmth) in a shirt pocket; rather, it should be kept in a jacket pocket or a purse. Headache often occurs with early use and diminishes in time. Acetaminophen may be used to treat headache.
The nurse is monitoring a male client with a spinal cord injury who is experiencing spinal shock. Which findings indicate that the spinal shock is resolving?
- A. Flaccidity
- B. Presence of a gag reflex
- C. Positive Babinski's reflex
- D. Development of hyperreflexia
- E. Return of the bulbocavernous reflex
- F. Return of reflex emptying of the bladder
Correct Answer: C,D,E,F
Rationale: Spinal shock is associated with acute injury to the spinal cord with temporary suppression of reflexes controlled by segments below the level of injury. It may last for 1 to 6 weeks. Indications that spinal shock is resolving include return of reflexes, development of hyperreflexia rather than flaccidity, and return of reflex emptying of the bladder. The return of the bulbocavernous reflex in male clients is also an early indicator of recovery from spinal shock. Babinski's reflex (dorsiflexion of the great toe with fanning of the other toes when the sole of the foot is stroked) is an early returning reflex. The gag reflex is not lost in spinal shock; therefore, its presence is not an indication of resolving spinal shock.
The nurse is providing instructions to the mother of a child with a diagnosis of strabismus of the left eye. Which statement by the mother indicates that the mother understands the procedure for patching?
- A. I will place the patch on both eyes.
- B. I will place the patch on the left eye.
- C. I will place the patch on the right eye.
- D. I will alternate the patch from the right eye to the left eye every hour.
Correct Answer: C
Rationale: Patching may be used for the treatment of strabismus to strengthen the weak eye. With this treatment, the good eye is patched; this encourages the child to use the weaker eye. The treatment is most successful when it is performed during the preschool years. The schedule for patching is individualized and prescribed by the ophthalmologist.