Nokea
The client has elected to have epidural anesthesia to relieve labor pain. If the client experiences hypotension, the nurse's first action should be:
- A. Place her in Trendelenburg position.
- B. Slow the IV infusion.
- C. Administer oxygen per nasal cannula.
- D. Speed the IV infusion of normal saline.
Correct Answer: D
Rationale: Hypotension from epidural anesthesia is treated by increasing IV fluid volume with normal saline to restore blood pressure, so D is correct. Trendelenburg is not recommended, slowing the IV would worsen hypotension, and oxygen is secondary.
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A client was admitted to the psychiatric unit with major depression after a suicide attempt. In addition to feeling sad and hopeless, the nurse would assess for
- A. Anxiety, unconscious anger, and hostility
- B. Guilt, indecisiveness, poor self-concept
- C. Psychomotor retardation or agitation
- D. Meticulous attention to grooming and hygiene
Correct Answer: C
Rationale: Psychomotor retardation or agitation. These are common physiologic symptoms of depression.
During the first 24 hours after total parenteral nutrition (TPN) therapy is started.
The nurse should
- A. monitor vital signs every two hours.
- B. determine urinalysis results.
- C. evaluate blood glucose levels.
- D. compare weight with the previous readings.
Correct Answer: C
Rationale: Strategy: Determine how each assessment relates to TPN. (1) inappropriate (2) inappropriate (3) correct-total parenteral nutrition (TPN), or hyperalimentation, has a high glucose content; important to monitor glucose levels (4) appropriate, but not a priority
A client has returned from having a transurethral prostatectomy. Which finding should be reported to the doctor immediately?
- A. An hourly urinary output of 40-50 mL
- B. Bright red urine with many clots
- C. Dark red urine with few clots
- D. Requests for pain med every 4 hours
Correct Answer: B
Rationale: Bright red urine with many clots indicates significant bleeding post-prostatectomy, requiring immediate reporting. Normal output is 40-50 mL/hour, dark red urine with few clots is expected, and pain med requests are routine.
The nurse prepares a 25-year-old woman for a cesarean section.
- A. What should the nurse’s response be based on regarding preoperative medication for a cesarean section?
- B. Contains a lower overall dosage of medication than is given before general surgery.
- C. Contains reduced amounts of sedatives and hypnotics than are given before general surgery.
- D. Contains reduced amounts of narcotics than are given before general surgery.
- E. Contains medications similar in type and dosages to those given before general surgery.
Correct Answer: C
Rationale: Preoperative medication for a cesarean section includes reduced amounts of narcotics to minimize respiratory depression in the newborn due to placental transfer. Sedatives and hypnotics are typically used in similar doses as in general surgery, and the overall dosage is not necessarily lower.
The nurse is caring for a 14-year-old girl admitted with an acute exacerbation of ulcerative colitis.
- A. What is the best nursing intervention for a 14-year-old with an acute exacerbation of ulcerative colitis?
- B. Encourage her mother to room in with her.
- C. Provide information on the hospital school program.
- D. Ask if she would like to have visits from friends.
- E. Involve her in planning her daily schedule.
Correct Answer: D
Rationale: Involving the adolescent in planning her daily schedule promotes autonomy and control, which is developmentally appropriate and therapeutic for managing chronic illness. Rooming in, school programs, and friend visits are supportive but less empowering for self-management.