Nokea
For each nursing action, click to specify if the nursing action is essential or contraindicated for the client.
- A. Assist the client with ambulation
- B. Inform the client to expect drowsiness
- C. Monitor for elevated temperature
- D. Assess for urinary retention
- E. Encourage the client to turn from side to side
Correct Answer: C,D,E
Rationale: Monitoring temperature, assessing urinary retention, and encouraging position changes are essential after epidural administration.
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After the nurse indicates chest pain protocol, which of the following is the priority diagnostic test?
- A. PT and INR
- B. 12 lead ECG
- C. Chest X-ray
- D. D-dimer test
Correct Answer: C
Rationale: The correct answer is C: Chest X-ray. When a patient presents with chest pain, a chest X-ray is crucial to evaluate for any acute cardiopulmonary conditions like pneumonia, pneumothorax, or aortic dissection. It helps identify any immediate life-threatening issues that require prompt intervention. PT and INR (A) are coagulation tests not typically indicated for acute chest pain. A 12-lead ECG (B) is important but usually done after the chest X-ray to assess for cardiac abnormalities. D-dimer test (D) is used to rule out pulmonary embolism, but it is not the priority test in the initial evaluation of chest pain.
A nurse in emergency department is caring for a three-year old child who has suspected epiglottitis. Which of the following actions should the nurse take?
- A. Prepare to assist with intubation
- B. obtain a throat culture
- C. suction the child's oropharynx
- D. prepare a cool mist tent
Correct Answer: A
Rationale: The correct action is A: Prepare to assist with intubation. Epiglottitis is a medical emergency where the airway can become severely compromised due to swelling of the epiglottis. Intubation may be necessary to secure the airway and ensure adequate oxygenation. Prompt intervention is crucial to prevent respiratory distress and potential death. Obtaining a throat culture (B) may delay essential treatment. Suctioning the oropharynx (C) can stimulate the epiglottis and worsen the obstruction. A cool mist tent (D) does not address the immediate need for securing the airway.
The nurse is initiating the client's plan of care. Which of the following Interventions should the nurse plan to implement?
- A. Provide a low-stimulation environment.
- B. Maintain bed rest.
- C. Give antihypertensive medication.
- D. Administer betamethasone
- E. Monitor intake and output hourly.
- F. Obtain a 24 hr urine specimen.
- G. Perform a vaginal examination every 12 hr.
Correct Answer: A,B,C,D,E,F
Rationale: The correct answer includes providing a low-stimulation environment (A) for client comfort, maintaining bed rest (B) to promote healing, giving antihypertensive medication (C) for blood pressure management, administering betamethasone (D) for specific medical needs, monitoring intake and output hourly (E) for fluid balance assessment, and obtaining a 24 hr urine specimen (F) for diagnostic purposes. These interventions are essential in addressing the client's physical and physiological needs during care planning. Performing a vaginal examination every 12 hr (G) is not typically indicated and may not be necessary unless specifically ordered for a particular condition.
The nurse should notify the provider for which of the following findings?
- A. Baseline fetal heart rate 115/min
- B. Three uterine contractions within 10 minutes
- C. Prolonged decelerations
- D. Moderate variability in the fetal heart rate
Correct Answer: C
Rationale: The correct answer is C: Prolonged decelerations. This finding indicates potential fetal distress, requiring immediate provider notification to assess and intervene. Baseline fetal heart rate (A) within normal range is reassuring. Three uterine contractions (B) could be normal. Moderate variability (D) is a positive sign of fetal well-being. The focus should be on abnormal findings like prolonged decelerations (C) that may indicate compromised fetal oxygenation.
Which information should the nurse include?
- A. This type of seizure can be mistaken for daydreaming
- B. Absence seizures typically last only a few seconds.
- C. The child may not remember the seizure episode afterward.
- D. There are usually no warning signs before an absence seizure occurs.
- E. Lip smacking or eye fluttering may accompany the seizure.
Correct Answer: E
Rationale: The correct answer is E because lip smacking or eye fluttering are common manifestations of absence seizures, providing crucial information for recognition and diagnosis. Choice A is incorrect as it does not specifically relate to absence seizures. Choice B is incorrect because absence seizures typically last 10-20 seconds, not just a few seconds. Choice C is incorrect as individuals experiencing absence seizures usually do not have memory issues afterward. Choice D is incorrect because some individuals may have warning signs before an absence seizure.