Nokea
For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.
- A. Irrigate indwelling urinary catheter with 50 mL of normal saline:
- B. Administer enema to relieve constipation
- C. Maintain bed rest for 2 days postoperatively
- D. Place a blanket rob under the client's knees while in bed.
- E. Apply warm compresses to the incision site.
Correct Answer:
Rationale: Rationales provided within the question context.
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Which of the following actions should the nurse take? Select all that apply.
- A. Have a second nurse confirm the information on the blood label
- B. Insert a large bore IV catheter
- C. Witness the client signing a consent for transfusion.
- D. Flush the transfusion tubing with dextrose SM in water.
- E. Explain to the client that transfusion reactions are not serious
Correct Answer: A,B
Rationale: The correct actions are A and B. A second nurse confirming the information on the blood label ensures accuracy and prevents errors. Inserting a large bore IV catheter allows for rapid transfusion and prevents complications. Choice C ensures informed consent but is not directly related to the transfusion process. Choice D is incorrect because dextrose cannot be used to flush transfusion tubing. Choice E is incorrect as it provides inaccurate information to the client.
Which of the following should the nurse identify as an expected finding?
- A. Weak femoral pulses
- B. Frequent nosebleeds
- C. Upper extremity hypotension
- D. Increased intracranial pressure
Correct Answer: A
Rationale: Coarctation of the aorta often results in weak or absent femoral pulses due to reduced blood flow to the lower extremities.
Which of the following actions should the nurse take?
- A. Place the client in a side-lying position prior to assessing the fetal heart rate.
- B. Measure the fundal height to determine the placement of the ultrasound stethoscope.
- C. Position the ultrasound stethoscope above the symphysis pubis to assess the fetal heart rate.
- D. Perform Leopold maneuvers prior to auscultating the fetal heart rate.
Correct Answer: C
Rationale: The correct answer is C: Position the ultrasound stethoscope above the symphysis pubis to assess the fetal heart rate. This is the correct action because placing the ultrasound stethoscope above the symphysis pubis allows for optimal detection of the fetal heart rate. This location is where the fetal heart sounds are best heard due to the proximity to the fetal heart. Placing the stethoscope in this location ensures accurate assessment of the fetal heart rate.
Choice A is incorrect because placing the client in a side-lying position is not necessary for assessing the fetal heart rate with an ultrasound stethoscope. Choice B is incorrect because measuring fundal height is not relevant to assessing the fetal heart rate. Choice D is incorrect because Leopold maneuvers are used to determine fetal position and presentation, not to assess the fetal heart rate.
A nurse is caring for a client who requires seclusion to prevent harm to others on the unit. Which of the following is an appropriate action for the nurse to take?
- A. Document the client's behavior prior to being placed in seclusion,
- B. Assess the client's behavior once every hour
- C. Offer fluids every 2 hr.
- D. Discuss with the client his inappropriate behavior prior to seclusion
Correct Answer: A
Rationale: The correct answer is A: Document the client's behavior prior to being placed in seclusion. This is important for legal and clinical reasons as it provides a clear record of the client's behavior leading up to seclusion, ensuring transparency and accountability. Assessing behavior once every hour (choice B) may not be sufficient for monitoring the client's condition in seclusion. Offering fluids every 2 hours (choice C) is important for hydration but not directly related to seclusion. Discussing inappropriate behavior with the client (choice D) may escalate the situation and is not recommended in this scenario.
Which of the following actions should the nurse take first?
- A. Meet with providers to discuss measures so decrease the infections
- B. Identify possible precipitating factors related to the infections
- C. Schedule nursing staff training for infection control procedures
- D. Revise the current policy for catheter care
Correct Answer: B
Rationale: Identifying causes directs targeted interventions.