Nokea
A woman with a 28 week pregnancy is on the way to the emergency department by ambulance with a tentative diagnosis of abruptio placenta. Which should the nurse do first when the woman arrives?
- A. administer oxygen by mask at 100%
- B. start a second IV with an 18 gauge cannula
- C. check fetal heart rate every 15 minutes
- D. insert urethral catheter with hourly urine outputs
Correct Answer: A
Rationale: administer oxygen by mask at 100%. Administering oxygen in this situation would increase the circulating oxygen in the mother's circulation to the fetus's circulation. This action will minimize complications.
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The nurse is applying silver sulfadiazine (Silvadene) to a child with severe burns to arms and legs. Which side effect should the nurse be monitoring for?
- A. Skin discoloration
- B. Hardened eschar
- C. Increased neutrophils
- D. Urine sulfa crystals
Correct Answer: D
Rationale: Urine sulfa crystals. When applied to extensive areas, silver sulfadiazine may cause a transient neutropenia, as well as renal function changes with sulfa crystals production and kernicterus.
Prior to administering Alteplase (TPA) to a client admitted for a cerebral vascular accident (CVA), it is critical that the nurse assess:
- A. Neuro signs
- B. Mental status
- C. Blood pressure
- D. PT/PTT
Correct Answer: D
Rationale: PT/PTT. TPA is a potent thrombolytic enzyme. Because bleeding is the most common side effect, it is most essential to evaluate clotting studies including PT, PTT, APTT, platelets, and hematocrit before beginning therapy.
The nurse is administering a topical ointment to the client's rash on the right leg. Which intervention should the nurse implement first?
- A. Don nonsterile gloves.
- B. Cleanse the client's right leg.
- C. Check the client's armband.
- D. Wash the hands for 15 seconds.
Correct Answer: D
Rationale: Hand washing is the first step to prevent infection, per aseptic technique. Gloves, cleansing, or armband checks follow.
The client recently has had a myocardial infarction. Which medications should the nurse anticipate the health-care provider recommending to prevent another heart attack?
- A. Vitamin K and a nonsteroidal anti-inflammatory drug.
- B. Vitamin E and a daily low-dose aspirin.
- C. Vitamin A and an anticoagulant.
- D. Vitamin B complex and an iron supplement.
Correct Answer: B
Rationale: Low-dose aspirin prevents platelet aggregation, reducing MI risk, per ACC/AHA guidelines. Vitamin E lacks evidence for secondary prevention; other options are irrelevant or contraindicated.
The nurse is administering diltiazem (Cardizem) to a client. Prior to administration, it is important for the nurse to assess which parameter?
- A. Temperature
- B. Blood pressure
- C. Vision
- D. Bowel sounds
Correct Answer: B
Rationale: Blood pressure. Diltiazem (Cardizem) is a calcium channel blocker that causes systemic vasodilation resulting in decreased blood pressure.