Nokea
A 22-year-old woman comes to the hospital at term in the early stages of labor. A diagnosis of complete placenta previa is made.
It would be MOST important for the nurse to take which of the following actions?
- A. Start an IV of terbutaline (Brethine) and monitor the patient's vital signs closely.
- B. Prepare the patient for an immediate cesarean section.
- C. Maintain the patient on bedrest until spontaneous vaginal delivery is achieved.
- D. Monitor the patient's length and duration of contractions.
Correct Answer: B
Rationale: Strategy: Answers are both assessments and implementations. Is the assessment appropriate? No. Determine the outcome of each implementation. Is it desired? (1) implementation, Brethine used to delay delivery in preterm labor (2) correct-implementation, cannot deliver vaginally (3) implementation, cannot deliver vaginally (4) assessment, cannot deliver vaginally, cesarean section must be performed
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The nurse is caring for a client with a history of asthma who is experiencing an acute exacerbation. Which of the following medications should the nurse administer FIRST?
- A. Albuterol nebulizer.
- B. Prednisone PO.
- C. Montelukast PO.
- D. Ipratropium inhaler.
Correct Answer: A
Rationale: Albuterol, a short-acting beta-agonist, is the first-line treatment for acute asthma exacerbations to relieve bronchospasm and improve airflow. Options B, C, and D are secondary: prednisone reduces inflammation, montelukast prevents attacks, and ipratropium is an adjunct.
Which of the following findings is consistent with a diagnosis of congestive heart failure?
- A. Jugular vein distention indicates increased fluid volume
- B. Carbon dioxide reading of 30
- C. Hemoglobin of 18
- D. Potassium level of 5.5
Correct Answer: A
Rationale: Jugular vein distention reflects increased fluid volume and right-sided heart failure, a hallmark of congestive heart failure. Other options are not specific to this condition.
The nurse is caring for a client who is receiving a continuous IV infusion of midazolam (Versed) for sedation. Which of the following findings should the nurse report immediately?
- A. Respiratory rate of 12 breaths/min
- B. Blood pressure of 100/60 mmHg
- C. Heart rate of 80 bpm
- D. Oxygen saturation of 90%
Correct Answer: D
Rationale: An oxygen saturation of 90% indicates hypoxemia, a serious midazolam side effect. Options A, B, and C are acceptable: respiratory rate is low but stable, BP is mildly low, and heart rate is normal.
The nurse is teaching the client with an ileal conduit regarding skin care to prevent excoriation. In addition to applying a well-fitted collection bag the client should be told to empty the collection bag:
- A. Every hour
- B. When it is half full
- C. Once daily
- D. When it is one-third full
Correct Answer: D
Rationale: The client should be told to empty the collection bag when it is one-third full. Answer A isn't necessary or feasible, so it is incorrect. Waiting until the collection bag is half full or more as suggested in answers B and C increases the likelihood of skin exposure to urine thereby contributing to excoriation.
The nurse is caring for a client with a history of multiple sclerosis.
- A. Which symptom is expected in a client with multiple sclerosis?
- B. Chest pain and shortness of breath.
- C. Muscle weakness and spasticity.
- D. Weight gain and edema.
- E. Persistent headaches.
Correct Answer: B
Rationale: Muscle weakness and spasticity are common in multiple sclerosis due to demyelination of nerve fibers. Chest pain, edema, and headaches are not typical symptoms.