Nokea
At approximately 6 PM, the nurse begins to open the nurses' notes for the evening shift. The last entry is noted for 1 PM, and there is no signature. The MOST appropriate nursing response is to
- A. leave approximately three or four lines for the day nurse to enter the day information and sign the chart.
- B. review with the client the activities after 1 PM, and enter what are determined to be the activities after 1 PM.
- C. begin charting on the next line below the last entry, and make a note for the day nurse to make a late entry to complete the chart.
- D. do not enter anything until the day nurse has been notified of the problem and returns to the unit to complete charting.
Correct Answer: C
Rationale: day nurse can make a 'late entry' to add any additional information
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The nurse is caring for a client with a history of seizures. The client begins to experience a tonic-clonic seizure. Which of the following actions should the nurse take FIRST?
- A. Restrain the client to prevent injury.
- B. Place a tongue depressor in the client's mouth.
- C. Turn the client to the side.
- D. Administer lorazepam (Ativan) IV.
Correct Answer: C
Rationale: turning the client to the side helps maintain a patent airway and prevents aspiration during a seizure
The nurse cares for an 8 lb, 8 oz newborn boy. The infant's history indicates that his mother was given magnesium sulfate IV 4 g in 250 ml D5W several hours before delivery. The nurse would be MOST concerned if which of the following was observed?
- A. Temperature 97.6°F (36.5°C).
- B. Apical pulse 140 bpm.
- C. Respirations 18.
- D. BP 80/50.
Correct Answer: C
Rationale: magnesium sulfate can cause slowing of respirations and hyporeflexia; normal respirations 30-60/min
A brace is ordered for a young teen with scoliosis. The nurse knows that teaching has been effective if the client makes which of the following statements?
- A. I will have my parents put bed-boards on my bed.
- B. I should decrease my caloric intake.
- C. I should only take tub baths.
- D. I can remove the brace for one hour a day.
Correct Answer: D
Rationale: should be worn at all times, except when bathing
The nurse is caring for a 22-year-old woman who is completing the first stage of labor. The woman's husband is at her side and has been coaching her according to exercises they learned at natural childbirth classes. Suddenly the woman begins to shake and screams, 'I can't stand this anymore!' The nurse should encourage the husband to
- A. instruct his wife to use shallow respirations during the contractions.
- B. offer his wife ice chips or sips of water to distract her from the pain.
- C. stroke his wife's abdomen between contractions.
- D. review with his wife the breathing pattern needed at each stage of labor.
Correct Answer: A
Rationale: entering transition phase of first stage of labor, slow shallow breaths needed (pant breathing)
Which of the following assessments would be a priority when documenting the nursing history of a two-year-old child?
- A. The child's rituals and routines at home.
- B. The child's understanding of hospitalization.
- C. The child's ability to be separated from the parents.
- D. The parent's methods for dealing with the child's temper tantrums.
Correct Answer: A
Rationale: during a crisis such as hospitalization, children are able to establish a sense of security through consistency of the rituals and routines from home