Nokea
The charge nurse on the postpartum unit has received report about a client with a fetal demise who has just delivered and will be ready for transfer out of Labor and Delivery in about 2 hours. The client has asked her primary nurse if she can stay on the unit since she found support from the nursing staff there. What action should the charge nurse on the postpartum unit take?
- A. Request a room for this client on a unit without newborns.
- B. Ask the nurse in labor and delivery to discharge the mother as soon as she is physically able to leave.
- C. Talk to the mother first and decide on a location that is mutually agreeable.
- D. Admit the mother to a private room on the postpartum unit.
Correct Answer: A
Rationale: Placing the client on a unit without newborns minimizes emotional distress from being near other newborns after a fetal demise.
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The nurse is caring for a client with a history of burns. Which of the following laboratory findings indicates a need for intervention?
- A. Serum potassium of 5.5 mEq/L.
- B. Serum sodium of 135 mEq/L.
- C. Hemoglobin of 12 g/dL.
- D. White blood cell count of 8,000/mm³.
Correct Answer: A
Rationale: Hyperkalemia (potassium 5.5 mEq/L) is a complication of burns due to tissue damage, requiring intervention.
A young adult has been bitten by a human and the skin on the forearm is broken. The client's last tetanus shot was about 8 years ago. The nurse should prepare the client to receive:
- A. An injection of tetanus toxoid.
- B. An application of a corticosteroid cream.
- C. Closure of the wound with sutures.
- D. Testing for tuberculosis.
Correct Answer: A
Rationale: A human bite with broken skin and a tetanus shot over 5 years ago warrants tetanus toxoid to prevent tetanus infection. The other options are not indicated for this scenario.
A client has soft wrist restraints to prevent her from pulling out her nasogastric tube. Which of the following nursing interventions should be implemented while the restraints are on the client?
- A. Instruct the client not to move while the restraints are in place
- B. Remove the restraints every 4 hours to provide skin care
- C. Secure the restraints to side rails of the bed
- D. Check on the client every 30 minutes while the restraints are on
Correct Answer: D
Rationale: Checking the client every 30 minutes ensures safety, circulation, and skin integrity while restraints are in use. Restraints should be removed every 2 hours for care, not 4, and securing to side rails is unsafe.
The nurse provides home care instructions to a client who is taking lithium carbonate. Which statement by the client indicates a need for further teaching?
- A. I need to take the lithium with meals.
- B. My blood levels must be monitored very closely.
- C. I need to decrease my salt and fluid intake while taking the lithium.
- D. I need to withhold the medication if I have excessive diarrhea or vomiting.
Correct Answer: C
Rationale: A normal diet and normal salt and fluid intake (1500 to 3000 mL per day) should be maintained because lithium decreases sodium reabsorption by the renal tubules, which could cause sodium depletion. A low-sodium intake causes a relative increase in lithium retention and could lead to toxicity. Lithium is irritating to the gastric mucosa; therefore, lithium should be taken with meals. Because therapeutic and toxic dosage ranges are so close, lithium blood levels must be monitored very closely: more frequently at first and then once every several months after that. The client should be instructed to withhold the medication if excessive diarrhea, vomiting, or diaphoresis occurs, and inform the primary health care provider if any of these problems arise.
A primary health care provider prescribes lipids (fat emulsion) for a client who is receiving total parenteral nutrition (TPN). The nurse should explain to the client that the fat emulsion is administered for which reason?
- A. To provide essential fatty acids
- B. As a supplement to fluid intake
- C. To decrease the risk of phlebitis
- D. Infused during the night in place of TPN
Correct Answer: A
Rationale: Lipids are a brand of intravenous fat emulsion administered to clients who are at risk for developing an essential fatty acid deficiency, such as those receiving TPN. Fat emulsions help meet caloric and nutritional needs that cannot be met by glucose administration alone. Fat emulsions are not administered to increase the amount of body fluids and they do not decrease the incidence of phlebitis. Fat emulsions neither replace TPN nor do they require infusion during the night.