Nokea
Before completing a nursing diagnosis, the nurse must first:
- A. Write goals and objectives
- B. Perform an assessment
- C. Plan interventions
- D. Perform evaluation
Correct Answer: B
Rationale: Assessment is the first step of nursing process.
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A newborn infant is exhibiting signs of respiratory distress. Which of the following would the nurse recognize as the earliest clinical sign of respiratory distress?
- A. Cyanosis
- B. Increased respirations
- C. Sternal and subcostal retractions
- D. Decreased respirations
Correct Answer: C
Rationale: Sternal and subcostal retractions are the earliest sign of respiratory distress in newborns, indicating increased ventilatory effort.
A client is being discharged from the hospital tomorrow following a colon resection with a left colostomy. The nurse knows that the client understands the discharge teaching about care of her colostomy when she says:
- A. I know that I am not supposed to irrigate my colostomy.'
- B. My stool will be soft like paste.'
- C. My stoma should be red and slightly raised.'
- D. The skin around my stoma may become irritated from the enzymes in my stool.'
Correct Answer: C
Rationale: The healthy stoma should be red and slightly raised. If it begins to turn dark or blue, the client should see the physician immediately.
A female client plans to bottle-feed her newborn. Her physician has ordered bromocriptine (Parlodel) to suppress lactation. Which of the following instructions about bromocriptine should be given by the nurse?
- A. Bromocriptine stimulates the production of prolactin.
- B. Hypertension is a primary side effect.
- C. Bromocriptine is generally taken for 5 days.
- D. Her blood pressure must be stable before starting bromocriptine.
Correct Answer: D
Rationale: Bromocriptine inhibits the secretion of prolactin. Hypotension is a side effect of this drug; hypertension is not. Bromocriptine is generally taken for 14 days. The administration of bromocriptine is delayed at least 4 hours postpartum and given only when the client's blood pressure is stable, because it can cause hypotension and syncope.
The nurse is caring for a client in labor. The fetal monitor shows early decelerations. The nurse should:
- A. Notify the physician immediately
- B. Reposition the client to her left side
- C. Continue to monitor the fetal heart rate
- D. Administer oxygen at 8-10 liters per minute
Correct Answer: C
Rationale: Early decelerations are benign caused by fetal head compression during contractions and do not indicate fetal distress. Continuing to monitor the fetal heart rate is appropriate. Repositioning oxygen or notifying the physician are unnecessary unless other abnormalities occur.
The nurse is caring for a client with a diagnosis of postpartum depression. Which symptom is most likely to be present?
- A. Persistent sadness
- B. Fever and chills
- C. Uterine tenderness
- D. Foul-smelling lochia
Correct Answer: A
Rationale: Postpartum depression is characterized by persistent sadness and low mood. Fever uterine tenderness and foul-smelling lochia suggest infection not depression.