Nokea
After delivering a healthy newborn, a client is experiencing postpartum hemorrhage. What initial intervention should the nurse implement?
- A. Administer IV fluids
- B. Perform a uterine massage
- C. Monitor the newborn's vital signs
- D. Notify the healthcare provider
Correct Answer: B
Rationale: The correct initial intervention for postpartum hemorrhage is to perform a uterine massage. This action helps the uterus contract, controlling bleeding. Administering IV fluids may be necessary but is not the initial intervention. Monitoring the newborn's vital signs is important but not the priority when managing postpartum hemorrhage. Notifying the healthcare provider can be done after initiating immediate interventions to address the hemorrhage.
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The nurse plans to evaluate the effectiveness of several drugs administered by different routes. Arrange the routes of administration from fastest to slowest rate of absorption. 1. Intravenous 2. Sublingual 3. Intramuscular 4. Subcutaneous
- A. 1,2,3,4
- B. 4,3,2,1
- C. 2,4,3,1
- D. 3,4,1,2
Correct Answer: A
Rationale: The correct order of routes of administration from fastest to slowest rate of absorption is 1. Intravenous, 2. Sublingual, 3. Intramuscular, 4. Subcutaneous. Intravenous administration provides the fastest absorption as the drug is directly injected into the bloodstream. Sublingual administration allows for rapid absorption through the mucous membranes under the tongue. Intramuscular administration has a slower absorption rate as the drug is injected into the muscle tissue. Subcutaneous administration is the slowest as the drug is injected into the fatty tissue under the skin, leading to a slower absorption compared to the other routes.
Prior to administering morphine sulfate (Morphine), the nurse takes the client's vital signs. Based on which finding should the nurse withhold administration of the medication until the charge nurse is notified?
- A. Temperature of 100.8°F
- B. A pulse rate of 150 beats per minute
- C. A respiratory rate of 10 breaths per minute
- D. A blood pressure of 180/110
Correct Answer: C
Rationale: The correct answer is C because a low respiratory rate is a critical concern when administering opioids like morphine, as they can suppress breathing. A high pulse rate (choice B) and high blood pressure (choice D) are not immediate contraindications for administering morphine. A slightly elevated temperature (choice A) may not necessarily require withholding morphine.
The healthcare provider is assessing a client who has just undergone a thoracentesis. Which finding should be reported immediately?
- A. Diminished breath sounds on the affected side.
- B. Pain at the procedure site.
- C. Blood-tinged sputum.
- D. Shortness of breath.
Correct Answer: D
Rationale: Shortness of breath should be reported immediately as it may indicate a pneumothorax, a potential complication of thoracentesis. Diminished breath sounds on the affected side, pain at the procedure site, and blood-tinged sputum are common findings post-thoracentesis and do not necessarily indicate immediate complications like a pneumothorax.
The nurse is caring for a client with a diagnosis of major depressive disorder who has been prescribed a selective serotonin reuptake inhibitor (SSRI). What is the most important teaching point?
- A. Take the medication with food.
- B. Expect to see improvement within 24 hours.
- C. Avoid drinking grapefruit juice.
- D. Report any thoughts of self-harm immediately.
Correct Answer: D
Rationale: The correct answer is D: 'Report any thoughts of self-harm immediately.' Clients prescribed SSRIs should be educated to report any thoughts of self-harm promptly, as these medications can initially increase suicidal ideation. Choice A is incorrect because SSRIs are usually taken on an empty stomach. Choice B is incorrect as it takes several weeks for SSRIs to reach their full effectiveness. Choice C is irrelevant to SSRI therapy.
A client is prescribed warfarin (Coumadin) for atrial fibrillation. Which dietary instruction should the nurse provide?
- A. Increase intake of green leafy vegetables
- B. Avoid foods high in vitamin K
- C. Increase intake of foods rich in vitamin C
- D. Limit intake of dairy products
Correct Answer: B
Rationale: The correct answer is B: 'Avoid foods high in vitamin K.' Vitamin K can decrease the effectiveness of warfarin, so it is essential for clients on warfarin therapy to avoid foods high in vitamin K. Green leafy vegetables are high in vitamin K, so choice A is incorrect. Choices C and D are unrelated to the dietary restrictions needed for clients taking warfarin and are therefore incorrect.