Nokea
After the anesthesiologist administers an epidural to a woman in labor, which of the following nursing actions has the HIGHEST priority?
- A. Decrease IV fluids.
- B. Assess the fetal heart monitor.
- C. Place the mother on her right side.
- D. Obtain the blood pressure.
Correct Answer: D
Rationale: Epidural anesthesia can cause hypotension, making blood pressure monitoring the priority to detect complications. Options A, B, and C are secondary or incorrect.
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A 16-year-old young woman is brought by her parents to the outpatient clinic for treatment of pelvic inflammatory disease (PID). While the nurse obtains a history, the client says bitterly, 'My parents are mean and don't really care about me.' Which of the following responses by the nurse is BEST?
- A. You feel your parents don't care about you?
- B. Your parents brought you to the clinic, didn't they?
- C. I am sure that your parents have your best interests at heart.
- D. Did you have a disagreement with your parents?
Correct Answer: A
Rationale: Reflecting the client’s feelings validates her emotions, encouraging therapeutic communication. Options B, C, and D are nontherapeutic, dismissing or challenging her statement.
The nurse is caring for a 10 year-old child who has just been diagnosed with diabetes insipidus. The parents ask about the treatment prescribed, vasopressin. What is priority in teaching the child and family about this drug?
- A. The child should carry a nasal spray for emergency use
- B. The family must observe the child for dehydration
- C. Parents should administer the daily intramuscular injections
- D. The client needs to take daily injections in the short-term
Correct Answer: A
Rationale: Diabetes insipidus results from reduced secretion of the antidiuretic hormone, vasopressin. The child will need to administer daily injections of vasopressin, and should have the nasal spray form of the medication readily available. A medical alert tag should be worn.
A client with acute glomerulonephritis requests a snack. Which snack is suitable given the client's dietary restrictions?
- A. Orange
- B. Banana
- C. Applesauce
- D. Raisins
Correct Answer: C
Rationale: Applesauce is a suitable snack for the client with acute glomerulonephritis. Answers A, B, and D are incorrect because oranges, bananas, and dried fruits such as raisins are high in potassium, which is restricted in the diet of the client with AGN.
Docusate sodium (Colace) is ordered for an adult who had a myocardial infarction yesterday. The client asks the nurse why docusate sodium is prescribed. The nurse's response should include which information?
- A. Colace is prescribed to make it take longer for blood to clot.
- B. Colace makes it easier for the client to relax and reduce stress.
- C. Colace helps lower cholesterol levels.
- D. Colace reduces straining at stool.
Correct Answer: D
Rationale: Docusate sodium is a stool softener, reducing straining during bowel movements, which decreases cardiac strain post-MI.
The nurse is to administer the daily dose of digoxin to an adult client. What is it essential for the nurse to do before administering the medication?
- A. Check the client's temperature
- B. Check the client's blood pressure
- C. Check the client's respirations
- D. Check the client's apical pulse
Correct Answer: D
Rationale: Digoxin slows heart rate; checking the apical pulse ensures it's above 60 bpm to avoid bradycardia. Temperature, blood pressure, and respirations are less critical.