Nokea
A client who is a gravida 2, para 1 has been admitted for induction of labor with oxytocin (Pitocin).
It would be MOST important for the nurse to take which of the following actions?
- A. Mix Pitocin in D5W, begin at 5 mg/cc as primary IV to gravity flow.
- B. Decrease the rate/flow of Pitocin if the fetal heart rate is below 150.
- C. Piggyback the Pitocin into the mainline IV and maintain the flow by gravity.
- D. Start an IV line and piggyback the Pitocin with an infusion pump.
Correct Answer: D
Rationale: Strategy: The topic of the question is unstated. Read the answer choices for clues. (1) Pitocin should be a secondary infusion (2) normal range for fetal heart tones is 120 to 160 beats per minute (3) rate should be maintained by an infusion pump (4) correct-Pitocin should always be a secondary infusion controlled by an IV pump
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The nurse is preparing to begin a dopamine (Intropin) infusion on a client.
Before beginning the infusion the nurse should
- A. evaluate the urine output.
- B. obtain the client's weight.
- C. determine the patency of the IV line.
- D. measure pulmonary artery pressures.
Correct Answer: C
Rationale: Strategy: Determine how each answer choice relates to dopamine. (1) not a critical assessment at this time (2) contains correct information, but is not a priority (3) correct-if extravasation occurs, there is sloughing of the surrounding skin and tissue; patent IV line is essential to prevent serious side effects (4) not a critical assessment at this time
Prior to a cesarean section delivery, a 24-year-old woman is treated for abruptio placentae. The nurse is caring for the woman during the postpartum period. Which of the following symptoms would be suggestive of disseminated intravascular coagulation (DIC)?
- A. The client's vital signs are: BP 90/58, temperature 101°F (38.3°C), pulse 112, respirations 18.
- B. The client's laboratory results are: Hgb 13 g/dL, Hct 40%, WBC 7,000/mm³.
- C. The client is nauseated, lethargic, and has vomited three times.
- D. There is oozing blood from the venipuncture site and abdominal incision.
Correct Answer: D
Rationale: DIC is acquired clotting disorder from overstimulation, prolonged oozing from sites of minor trauma first symptom
A 36-year-old man has a flaccid bladder following a spinal cord injury. The nurse is teaching the client about dietary changes. Which of the following beverages, if selected by the client, would indicate to the nurse that teaching was effective?
- A. Lemonade.
- B. Prune juice.
- C. Milk.
- D. Orange juice.
Correct Answer: B
Rationale: promotes acidic urine, minimizes risk of urinary tract infection and stone formation, also use cranberry, tomato juice, bouillon
The nurse is caring for clients in the skilled nursing facility.
- A. Which client requires the nurse’s immediate attention?
- B. A client admitted for a cerebral vascular accident (CVA) whose prescription for warfarin (Coumadin) expired two days ago.
- C. A client in pain who was receiving morphine in an acute care institution and was transferred with a prescription for acetaminophen with codeine.
- D. A client who has dysuria and foul-smelling, cloudy, dark amber urine.
- E. An immunosuppressed client who has not received an influenza immunization.
Correct Answer: A
Rationale: A client with an expired warfarin prescription post-CVA is at high risk for recurrent stroke due to the anticoagulant’s 2-5 day duration, requiring immediate attention. Pain management, urinary symptoms, and immunization are less urgent.
The home care nurse instructs the wife of a client about how to perform a wet-to-dry abdominal dressing for her husband with an infected abdominal incision. The nurse should intervene in which of the following situations?
- A. The wife wets the old dressing with sterile saline before removing it.
- B. The wife covers the wound with wet, sterile 4 × 4s.
- C. The wife irrigates the wound with hydrogen peroxide using a bulb syringe.
- D. The wife uses Montgomery straps to secure the dressing.
Correct Answer: A
Rationale: contraindicated, remove dry so wound debris and necrotic tissue are removed with old dressing