Nokea
The client has been in active labor for the last 12 hours. During the last 3 hours, labor has been augmented with oxytocin because of hypoactive uterine contractions. Her physician assesses her cervix as 95% effaced, 8 cm dilated, and the fetus is at 0 station. Her oral temperature is 100.2F at this time. The physician orders that she be prepared for a cesarean delivery. In preparing the client for the cesarean delivery, which one of the following physician's orders should the RN question?
- A. Administer meperidine (Demerol) 100 mg IM 1 hour prior to the delivery.
- B. Discontinue the oxytocin infusion.
- C. Insert an indwelling Foley catheter prior to delivery.
- D. Prepare abdominal area from below the nipples to below the symphysis pubis area.
Correct Answer: A
Rationale: Meperidine crosses the placental barrier and can cause respiratory depression in the fetus, making it inappropriate for preoperative cesarean delivery.
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A client who uses a respiratory inhaler asks the nurse to explain how he can know when half his medication is empty so that he can refill his prescription. The nurse should tell the client to:
- A. Shake the inhaler and listen for the contents.
- B. Drop the inhaler in water to see if it floats.
- C. Check for a hissing sound as the inhaler is used.
- D. Press the inhaler and watch for the mist.
Correct Answer: B
Rationale: Dropping the inhaler in water to see if it floats is a practical way to estimate remaining medication; a half-empty inhaler will float, while a full one sinks.
A male client is admitted to the psychiatric unit after experiencing severe depression. He states that he intends to kill himself, but he asks the nurse not to repeat his intentions to other staff members. Which response demonstrates understanding and appropriate action on the part of the nurse?
- A. I understand you're depressed, but killing yourself is not a reasonable option.'
- B. We need to discuss this further, but right now let's complete these forms.'
- C. Don't do that, you have so much to live for. You have a wonderful wife and children. The client in the next room has no one.'
- D. This is very serious. I do not want any harm to come to you. I will have to report this to the rest of the staff.'
Correct Answer: D
Rationale: To the client, suicide may be a reasonable action and the only one he can cope with at this time. This response indicates to the client that his intention to commit suicide is not important to the nurse at this time. The client is so depressed that he is not able to see the positive aspects of his life. At no time should the nurse discuss another client's problems in conversation. This statement tells the client that the nurse recognizes his problem is of a serious nature and will take all steps necessary to help him.
Before giving methergine postpartum, the nurse should assess the client for:
- A. Decreased amount of lochial flow
- B. Elevated blood pressure
- C. Flushing
- D. Afterpains
Correct Answer: B
Rationale: Methergine is given to contract the uterus and to control postpartal hemorrhage; therefore, lochial flow should decrease. Methergine may elevate the blood pressure. A client with an elevated blood pressure should not receive methergine, but she could be given oxytocin if necessary. Flushing is not a side effect of methergine. Afterpains are increased with methergine usage. The client should be informed that this is a normal response.
Primary nursing diagnoses for the antisocial client are:
- A. Alteration in perception and altered self-concept
- B. Impaired social interaction, ineffective individual coping, and altered self-concept
- C. Altered communication processes and altered recreational patterns
- D. Altered body image and altered thought processes
Correct Answer: B
Rationale: This answer is incorrect. Perception is not altered because the client is not psychotic. This answer is correct. The antisocial client lacks responsibility, accountability, and social commitment; has impaired problem-solving ability; tends to overuse defense mechanisms; lies and steals; and is often grandiose concerning self. This answer is incorrect. Altered communication processes do not characterize this client. The antisocial person communicates well and tends to have a charming personality. This answer is incorrect. Altered thought processes refer to delusional thinking, which is bizarre and fixed, and do not characterize this client.
A 17-year-old pregnant client who is gravida 1, para 0, is at 36 weeks' gestation. Based on the nurse's knowledge of the maternal physiological changes in pregnancy, which of these findings would be of concern?
- A. Complaints of dyspnea
- B. Edema of face and hands
- C. Pulse of 65 bpm at 8 weeks, 73 bpm at 36 weeks
- D. Hematocrit 39%
Correct Answer: B
Rationale: Edema of the face, hands, or pitting edema after 12 hours of bed rest may be indicative of preeclampsia and would be of great concern to the healthcare provider.