Nokea
An adult had major abdominal surgery this morning under general anesthesia. When the client arrives in the recovery room, she is very lethargic and restless. Her BP is 150/98; pulse is 110 and irregular; and respirations are 30 breaths per minute and shallow. Postoperative orders include meperidine (Demerol) 75 mg IM for operative site pain; reinforce dressings PRN; oxygen at 6 L/min PRN; irrigate nasogastric tube every 2 hours and PRN; IV 2500 cc D5W in 24 hours. What should the nurse do next?
- A. Carefully inspect the dressings for any drainage
- B. Irrigate the nasogastric tube
- C. Administer meperidine (Demerol) as ordered
- D. Administer oxygen
Correct Answer: D
Rationale: Tachypnea, tachycardia, and restlessness suggest hypoxia. Administering oxygen at 6 L/min addresses this critical need. Dressings, nasogastric irrigation, and pain medication are secondary to stabilizing oxygenation.
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A 21-year-old primipara in active labor.
The nurse observes a new graduate nurse palpating the uterine contractions of a 21-year-old primipara in active labor. Which of the following actions, if taken by the new graduate nurse, is MOST appropriate?
- A. The graduate nurse places the palm of one hand on the fundus and moves the hand around the abdomen.
- B. The graduate nurse places the heels of both hands on the lower abdomen and presses lightly.
- C. The graduate nurse places one hand on the abdomen over the fundus and with the fingertips, presses gently.
- D. The graduate nurse places the palms of the hands on either side of the abdomen and presses firmly.
Correct Answer: C
Rationale: Strategy: 'MOST appropriate' indicates that this is a priority question. All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) palpations should be done with fingertips, not palms of hands (2) palpations should be done with fingertips, not heels of hands (3) correct-done with fingertips (4) palpations should be done with fingertips, not palms of hands
For which of the following mother-baby pairs should the nurse review the Coombs' test in preparation for administering Rh0 (D) immune globulin within 72 hours of birth?
- A. Rh negative mother with Rh positive baby
- B. Rh negative mother with Rh negative baby
- C. Rh positive mother with Rh positive baby
- D. Rh positive mother with Rh negative baby
Correct Answer: A
Rationale: Rh negative mother with Rh positive baby. Rh0 (D) immune globulin is administered to prevent Rh sensitization in an Rh-negative mother who may have been exposed to Rh-positive fetal blood during delivery. The Coombs' test helps determine if the baby is Rh-positive, confirming the need for the injection.
What is the most important consideration when teaching parents how to reduce risks in the home?
- A. Age and knowledge level of the parents
- B. Proximity to emergency services
- C. Number of children in the home
- D. Age of children in the home
Correct Answer: D
Rationale: Age of children in the home. Safety measures must be tailored to the developmental stage of the children.
A client is placed on cephalexin monohydrate (Keflex) prophylactically after surgery.
Which of the following foods should the nurse encourage?
- A. Bran cereals and fruits.
- B. Egg whites and lean meats.
- C. Yogurt and acidophilus milk.
- D. Fish and poultry meats.
Correct Answer: C
Rationale: Strategy: The topic of the question unstated. Read the answer choices for clues. (1) unnecessary to encourage (2) unnecessary to encourage (3) correct-these foods will help maintain normal inTest inal flora, which may be altered by the Keflex (4) unnecessary to encourage
An extremely angry patient with bipolar illness who just learned his wife has filed for divorce.
Which of the following responses by the nurse is MOST appropriate?
- A. Allow the patient to use the phone.
- B. Confront the patient about his anger and inappropriate plan of action.
- C. Do not allow the patient to use the phone because he is an involuntary patient.
- D. Set limits on the patient's phone use because he has been unable to control his behavior.
Correct Answer: A
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-patient is able to use phone unless otherwise indicated by court order or physician's order (2) has not lost civil right to use phone (3) denies patient his civil rights (4) inappropriate