Nokea
Methylergonovine maleate is prescribed for a woman who has just delivered a healthy newborn. Which is the priority assessment to complete before administering the medication?
- A. Lochia
- B. Uterine tone
- C. Blood pressure
- D. Deep tendon reflexes
Correct Answer: C
Rationale: Methylergonovine maleate, an oxytocic, is an agent used to prevent or control postpartum hemorrhage by contracting the uterus. The immediate dose is administered intramuscularly, and then, if still needed, it is administered orally. It causes uterine contractions and may elevate the blood pressure. A priority assessment before administration of methylergonovine maleate is blood pressure. Methylergonovine maleate is to be administered cautiously in the presence of hypertension, and the primary health care provider should be notified if hypertension is present. Options 1 and 2 are general components of care in the postpartum period. Option 4 is most specifically related to the administration of magnesium sulfate.
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A client who voluntarily admitted herself to the mental health hospital adamantly demands to be discharged immediately. What is the most appropriate response by the nurse?
- A. We hate to see you go, but that is your right. I'll get the forms for you so you can go.'
- B. I'm sorry, but your lawyer or family must request such forms when you are hospitalized.'
- C. I will get the forms, but your psychiatrist will need to see you before you leave.'
- D. Are you sure we can't convince you to stay here in a few days? You'll return to a full valid and there are several issues we need to address.'
Correct Answer: C
Rationale: For voluntary admissions, clients can request discharge, but a psychiatric evaluation is typically required to ensure safety. This response ensures protocol is followed while addressing the client's request.
Conflicts, according to Lewin, include which types of conflict? Select all that apply.
- A. Conceptualization conflicts
- B. Avoidance - Avoidance conflicts
- C. Approach - Approach conflicts
- D. Resolvable conflicts
- E. Unresolvable conflicts
- F. Double Approach - Avoidance conflicts
- G. Approach-Avoidance conflicts
Correct Answer: B,C,F,G
Rationale: According to Lewin's conflict theory, the types of conflict include Avoidance-Avoidance , Approach-Approach , Double Approach-Avoidance (F), and Approach-Avoidance (G). Conceptualization, resolvable, and unresolvable conflicts are not part of Lewin's framework.
The nurse is reviewing the client's arterial blood gas results. Which finding would indicate that the client is experiencing respiratory acidosis?
- A. pH 7.5, PcO2 of 30
- B. pH 7.3, PcO2 of 50
- C. pH 7.3, HCO3 of 19
- D. pH 7.5, HCO3 of 30
Correct Answer: B
Rationale: In respiratory acidosis, the pH is decreased and an opposite effect is seen in the PCO2 (pH decreased, PCO2 elevated). Option 1 indicates respiratory alkalosis; option 3 indicates possible metabolic acidosis; option 4 indicates possible metabolic alkalosis.
The nurse is caring for a client with a history of heart failure who is receiving furosemide (Lasix). Which laboratory value should the nurse monitor closely?
- A. Serum potassium
- B. Serum calcium
- C. Serum glucose
- D. Serum cholesterol
Correct Answer: A
Rationale: Furosemide, a loop diuretic, can cause hypokalemia due to potassium loss in urine. Monitoring serum potassium is critical to prevent arrhythmias or muscle weakness.
Place the following steps for mixing NPH and regular insulin in the proper sequential order from # 1 to # 6 below. #1 - Prep the top of the shorter acting insulin with an alcohol swab #2 - Inject air that is equal to the ordered dosage of the shorter acting insulin using the same insulin syringe. #3 - Withdraw the ordered dosage of the shorter acting insulin using the same insulin syringe. #4 - Prep the top of the longer acting insulin vial with an alcohol swab. #5 - Inject air that is equal to the ordered dosage of the longer acting insulin using the insulin syringe. #6 - Withdraw the ordered dosage of the longer acting insulin using the same insulin syringe.
- A. 1,5,4,2,3,6
- B. 4,3,2,6, 1,5
- C. 4,2,5,3, 1,6
- D. 1,5,3,6,4,2
Correct Answer: A
Rationale: The correct sequence is: 1) Prep short-acting insulin vial, 2) Inject air into short-acting vial, 3) Withdraw short-acting insulin, 4) Prep long-acting insulin vial, 5) Inject air into long-acting vial, 6) Withdraw long-acting insulin to avoid contamination.