Nokea
A nurse in an emergency department is assessing a client who reports ingesting thirty diazepam tablets a respiratory rate of 10/min.
After securing the client's airway and initiating an IV, which of the following actions should the nurse do next.
- A. Administer flumazenil to the client.
- B. Initiate gastric lavage with activated charcoal.
- C. Place the client in the Trendelenburg position.
- D. Obtain a stat CT scan of the brain.
Correct Answer: A
Rationale: The correct answer is A: Administer flumazenil to the client. Flumazenil is a specific benzodiazepine receptor antagonist used to reverse the effects of benzodiazepine overdose, which includes respiratory depression. Administering flumazenil would help reverse the sedative effects of benzodiazepines and improve the client's respiratory status. Initiating gastric lavage with activated charcoal (B) is not the immediate priority after securing the airway and IV. Placing the client in the Trendelenburg position (C) is not recommended due to potential complications. Obtaining a stat CT scan of the brain (D) is not necessary at this point and does not address the immediate concerns of airway and sedation reversal.
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A nurse is caring for a client who has placenta previa.
Which finding should the nurse expect?
- A. Spotting
- B. Painless, bright red vaginal bleeding
- C. Soft, relaxed, and non-tender uterus
- D. Fundal height greater than expected for gestational age
- E. Fetal heart rate within normal limits unless significant blood loss occurs
Correct Answer: B
Rationale: The correct answer is B: Painless, bright red vaginal bleeding. This finding is indicative of placenta previa, a condition where the placenta partially or completely covers the cervix. The bright red color indicates fresh bleeding. Spotting (choice A) is more commonly associated with implantation bleeding in early pregnancy. A soft, relaxed, and non-tender uterus (choice C) is not specific to any particular condition. A fundal height greater than expected for gestational age (choice D) could indicate fetal macrosomia or polyhydramnios, but it is not related to the scenario described. While fetal heart rate within normal limits (choice E) is important, it is not the most relevant finding in this case.
A nurse is planning care for a school-age child who is 4 hr postoperative following perforated appendicitis. Which of the following actions should the nurse include in the plan of care?
- A. Offer small amounts of clear liquids 6 hr following surgery
- B. Administer analgesics on a scheduled basis for the first 24 hr
- C. Give cromolyn nebulized solution every 8 hr
- D. Apply a warm compress to the operative site every 4 hr
Correct Answer: B
Rationale: The correct answer is B: Administer analgesics on a scheduled basis for the first 24 hr. Postoperative pain management is crucial for the comfort and well-being of the child. Scheduled analgesics help maintain a consistent level of pain relief, preventing peaks and valleys in pain intensity. This approach is especially important in the initial 24 hours following surgery when pain is typically more intense. Offering small amounts of clear liquids 6 hours post-surgery (Choice A) may not be appropriate as the child may still be recovering from anesthesia and at risk of nausea or vomiting. Giving cromolyn nebulized solution every 8 hours (Choice C) is not indicated for postoperative pain management. Applying a warm compress to the operative site every 4 hours (Choice D) may provide some comfort but does not address the underlying need for analgesia.
A nurse is caring for a client who is in labor Nurses' Notes
0900:
Contractions occurring every 3 to 4 min, lasting 80 to 90 seconds. Client rates pain with
contractions as 10 on a scale of 0 to 10 and requests an epidural.
Contractions approximately 4 min apart. Vaginal examination reveals cervix dilated 5 cm, 80%
effaced, -1 station, vertex presentation. FHR baseline 142/min with moderate variability. IV fluid
bolus initiated.
0930:
Epidural inserted by anesthesiology. Client reports pain as 2 on a scale of 0 to 10.
0950:
Spontaneous rupture of membranes with clear fluid. 1000:
Variable decelerations noted on the electronic fetal heart rate monitor tracing, FHR baseline
140/min, Deceleration 90/min, tasting 30 seconds: Loop of umbilical cord visible at vaginal
Vital Signs
0900:
Temperature 36.5 C (97.7 F) BP
130/84 mm Hg
Heart rate 108/min
Respiratory rate 18/min
Oxygen saturation 98% on room air
0930:
BP 120/78 mm Hg Heart rate
96/min Respiratory rate
18/min
Oxygen saturation 98% on room air
1000
BP 118/84 mm Hg Heart rate
95/min Respiratory rate
19/min
Oxygen saturation 97% on room air
Select the 5 actions the nurse should take.
- A. Increase the flow rate of the maintenance IV fluid.
- B. Have the charge nurse notify the provider.
- C. Place the client in a Trendelenburg position.
- D. Exert upward pressure on the presenting part.
- E. Attempt to push the umbilical cord back into the cervix.
- F. Administer oxygen at 10 L/min Via nonrebreather face mask
Correct Answer: A,B,C,D,E
Rationale: Correct Answer: A, B, C, D, E
Rationale:
A: Increasing IV fluid flow rate helps maintain hydration and blood pressure.
B: Notifying the provider ensures timely medical intervention and documentation.
C: Placing the client in Trendelenburg position helps improve placental perfusion.
D: Exerting upward pressure on presenting part can alleviate pressure on the cord.
E: Attempting to push the umbilical cord back can prevent cord compression and fetal distress.
Summary:
F: Administering oxygen may be beneficial but not among the immediate actions required.
G: No information provided about this choice.
A home health nurse is planning care for a client who has Alzheimer's disease.
Which of the following actions should the nurse include in the plan of care?
- A. Encourage physical activity prior to bedtime
- B. Replace the carpet with hardwood floors
- C. Wear clothing with zippers instead of buttons
- D. Place locks at the top of exterior doors
Correct Answer: D
Rationale: The correct answer is D: Place locks at the top of exterior doors. This action is crucial in ensuring the safety and security of the individual, especially in cases where the person may be at risk of wandering or elopement. Placing locks at the top of exterior doors can prevent the individual from leaving the house unsupervised, which is essential for their safety. Encouraging physical activity prior to bedtime (A) may disrupt sleep patterns. Replacing carpet with hardwood floors (B) is not directly related to the safety of the individual. Wearing clothing with zippers instead of buttons (C) may be a personal preference but does not address safety concerns.
A nurse is caring for a client who has a stool culture that is positive for Clostridium difficile.
Which of the following infection control precautions should the nurse take?
- A. Remove the protective gown while in the client's room.
- B. Place the client in a private room with contact precautions.
- C. Perform hand hygiene using an alcohol-based sanitizer.
- D. Wear an N95 mask when entering the client's room.
Correct Answer: B
Rationale: The correct answer is B: Place the client in a private room with contact precautions. This is the most appropriate infection control measure for preventing the spread of infections. Placing the client in a private room helps to prevent transmission to other individuals. Contact precautions involve using gloves and gowns when in contact with the client or their environment, further reducing the risk of transmission. Choices A, C, and D are incorrect. Removing the protective gown while in the client's room (A) increases the risk of contamination. Hand hygiene using an alcohol-based sanitizer (C) is important but alone is not sufficient for contact precautions. Wearing an N95 mask when entering the client's room (D) is not necessary unless the client has airborne precautions.