Nokea
For each potential intervention, click to specify if the intervention is anticipated or contraindicated for the client.
- A. Monitor blood pressure every hour
- B. Maintain continuous monitoring of the FHR
- C. Initiate an IV infusion of lactated Ringers
- D. Place the client in a left lateral position
Correct Answer: A,B,D
Rationale: Monitoring blood pressure, maintaining continuous FHR monitoring, and placing the client in a left lateral position are all anticipated interventions in labor management.
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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.
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.
A nurse is preparing to admit a six-year-old with varicella to the pediatric unit. Which of the following actions should the nurse take?
- A. Assign the child to a negative air pressure room (airborne)
- B. Place the child in a semi-private room with another child who has varicella
- C. Require the child to wear a surgical mask at all times
- D. Ensure the child's visitors wear droplet precautions
Correct Answer: A
Rationale: The correct answer is A: Assign the child to a negative air pressure room (airborne). This is because varicella (chickenpox) is transmitted through airborne droplets. Placing the child in a negative air pressure room helps prevent the spread of the virus to others.
B: Placing the child in a semi-private room with another child who has varicella increases the risk of spreading the infection to each other.
C: Requiring the child to wear a surgical mask at all times may help reduce the spread of droplets, but it does not address the airborne transmission of varicella effectively.
D: Ensuring the child's visitors wear droplet precautions is not sufficient to prevent airborne transmission within the unit.
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.
Which of the following should the nurse use to assess the port?
- A. An Angio catheter
- B. A butterfly needle
- C. A noncoring needle
- D. A 25-gauge needle
Correct Answer: C
Rationale: The correct answer is C: A noncoring needle. To assess a port, a noncoring needle should be used because it is specifically designed for accessing ports without damaging the septum. Using an Angio catheter (A) may be too large and cause damage, a butterfly needle (B) is not suitable for accessing ports, and a 25-gauge needle (D) may be too small or not specifically designed for port access. Noncoring needles are the standard choice for accessing ports due to their design that minimizes trauma and ensures proper function.