Nokea
A nurse is caring for a newborn.
Nurses' Notes
0640:
Weight 4200 gm (9 lb 4 oz), head circumference 35.5 cm (14 in)
Respiratory rate 68/min, with mild grunting.
0650:
Respiratory rate 72/min, with mild grunting
0700:
Respiratory rate 76/min, with moderate grunting and mild intercostal retractions.
The client is at risk for developing------- and----
- A. bronchopulmonary dysplasia
- B. transient tachypnea of the newborn
- C. tachycardia
- D. hypopycemia
Correct Answer: B,D
Rationale: Transient tachypnea and hypopycemia are common risks in newborns with respiratory distress.
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A nurse is caring for a client of a psychiatric unit
Nurses' Notes
0700
Client is admitted to the unit. They deny suicidal ideations at this time. Client states, "I am an
assistant to a powerful spirit." Client is poorly groomed and has body odor.
0900:
Called to the client's room, Client states, "I cannot believe you put me in a room with spiders on
the wall. " Client requests immediate transfer to another room.
1200:
Psychiatrist is at the bedside evaluating the client. After history and physical, psychiatrist states
that they have diagnosed the client with schizophrenia.
Client is to be started on medication and milieu therapy History and
Physical
0700
Majority of client's history is obtained from client's parent who presents with client today.
According to the parent, client has been acting strangely for a few months. Client's symptoms
have been progressively worsening.
In the last month, the client has been seeing things that are not present and believes that they are
in a close relationship with "a powerful spirit." Client has not been bathing regularly for the last
few weeks.
Client has no significant health history. Client reports that they do not take illicit substances or
drink alcohol. Client's grandparent has a history of schizophrenia
For each potential action, click to specify if the action is indicated or contraindicated for the client.
- A. Allow the client to watch TV at high volume
- B. Ask the client about the content of their hallucinations
- C. Instruct the client on expected hygiene practices
- D. Assess the client for suicidal ideation
- E. Place the client in a room near the activity room
Correct Answer: B,D
Rationale: [
B: Asking the client about the content of their hallucinations is indicated to gather important information for assessment and treatment planning.
D: Assessing the client for suicidal ideation is crucial to ensure their safety and provide appropriate interventions.
A: Allowing the client to watch TV at high volume is contraindicated as it may exacerbate symptoms or disturb others.
C: Instructing the client on expected hygiene practices may not be a priority compared to assessing hallucinations and suicidal ideation.
E: Placing the client in a room near the activity room is not mentioned in the question and does not address the client's immediate needs.]
A nurse is consulting A pharmacological reference about medication compatibility prior to administering warfarin to a client.
Which of the following medications should the nurse identify as being incompatible with warfarin?
- A. Naproxen
- B. Metformin
- C. Lisinopril
- D. Albuterol
Correct Answer: A
Rationale: The correct answer is A: Naproxen. Naproxen is a nonsteroidal anti-inflammatory drug (NSAID) that can increase the risk of bleeding when taken with warfarin, an anticoagulant. This is due to their combined effects on blood clotting. Metformin, Lisinopril, and Albuterol do not have a significant interaction with warfarin in terms of bleeding risk. Therefore, the nurse should identify Naproxen as incompatible with warfarin to prevent potential adverse effects.
A nurse manager is updating protocols for the use of belt restraints.
Which of the following guidelines should the nurse include?
- A. Document the client's condition every 15 minutes.
- B. Attach the restraint straps to the side rails of the bed.
- C. Use a square knot to secure the restraint.
- D. Ensure there is at least a 2-inch gap between the restraint and the client's body.
Correct Answer: A
Rationale: The correct answer is A: Document the client's condition every 15 minutes. This guideline is crucial for monitoring the client's status, detecting any changes promptly, and ensuring their safety. Documenting every 15 minutes allows for timely intervention and assessment.
Choice B is incorrect because attaching restraint straps to the side rails can lead to entrapment and harm.
Choice C is incorrect as a square knot is not recommended for securing restraints due to the risk of difficulty in quick release during emergencies.
Choice D is incorrect as a 2-inch gap between the restraint and the client's body can increase the risk of injury or self-removal.
A nurse is caring for a client in the active phase of labor who has decided to have a natural childbirth.
Which pain management technique should the nurse suggest?
- A. Provide information about the use of hydrotherapy during labor
- B. Encourage the use of breathing techniques to manage pain.
- C. Suggest the use of massage or counterpressure to relieve discomfort.
- D. Recommend positioning changes, such as walking or rocking, to ease pain.
- E. Support the use of relaxation techniques, such as visualization, to reduce stress.
Correct Answer: B
Rationale: The correct answer is B: Encourage the use of breathing techniques to manage pain. Breathing techniques help in pain management by promoting relaxation, reducing anxiety, and increasing oxygen flow. This can help the laboring individual cope better with contractions. Other choices are less effective for pain management in labor. A: Hydrotherapy can be beneficial, but breathing techniques are more universally applicable. C: Massage and counterpressure can help, but may not be as effective as breathing techniques during labor. D: Positioning changes are helpful, but breathing techniques are more directly focused on pain management. E: Relaxation techniques like visualization are useful, but breathing techniques are more specifically targeted at managing pain.
A charge nurse is concerned about a recent increase in facility-acquired catheter infections.
Which action should the nurse take?
- A. Identify possible precipitating factors related to the infection
- B. Reinforce proper hand hygiene practices among staff.
- C. Implement a protocol for timely removal of unnecessary catheters.
- D. Provide staff education on aseptic catheter insertion techniques.
- E. Conduct regular audits on catheter care compliance.
Correct Answer: E
Rationale: The correct action for the nurse to take is E: Conduct regular audits on catheter care compliance. Audits help monitor adherence to catheter care protocols, identify areas needing improvement, and ensure staff follow best practices consistently. This action promotes quality care, reduces infection risks, and enhances patient safety. Choices A, B, C, and D are important but do not directly address ongoing monitoring and assessment of compliance like regular audits do. Conducting audits is a proactive approach to continuously evaluate and improve catheter care practices, making it the most appropriate action in this scenario.