Nokea
The graduate nurse is assigned to care for the client on ventilator support, pending organ donation. Which goal should receive priority?
- A. Maintaining the client's systolic blood pressure at 70 mmHg or greater
- B. Maintaining the client's urinary output greater than 300 cc per hour
- C. Maintaining the client's body temperature of greater than 33°F rectal
- D. Maintaining the client's hematocrit at less than 30%
Correct Answer: A
Rationale: Adequate blood pressure ensures organ perfusion for donation.
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Twenty micrograms (g) are equal to how many milligrams? Record your answer using a decimal number.
Correct Answer: 0.02
Rationale: 1 mg = 1,000 g, so 20 /1,000 = 0.02 mg.
A client telephones the emergency room stating that she thinks that she is in labor. The nurse should tell the client that labor has probably begun when:
- A. Her contractions are 2 minutes apart.
- B. She has back pain and a bloody discharge.
- C. She experiences abdominal pain and frequent urination.
- D. Her contractions are 5 minutes apart.
Correct Answer: D
Rationale: Contractions 5 minutes apart indicate the onset of active labor, prompting further evaluation.
Which statement is incorrect regarding the Federal Nursing Home Reform Act from the Omnibus Budget Reconciliation Act of 1987 (OBRA '87)?
- A. the right to be free of unnecessary chemical restraints
- B. the right to choose a personal physician
- C. the right to access medical records
- D. the right to organize hospital personnel within a union
Correct Answer: D
Rationale: OBRA '87 does not include the right to organize hospital personnel into a union. Other rights are part of the act.
The nurse notes variable decelerations on the fetal monitor strip. The most appropriate initial action would be to:
- A. Notify her.Concurrent doctor
- B. Increase the rate of IV fluid
- C. Reposition the client
- D. Readjust the monitor
Correct Answer: C
Rationale: Repositioning the client can relieve umbilical cord compression, the common cause of variable decelerations.
A nurse working in ICU has a client on a propofol (Diprivan) drip while on the mechanical ventilator. The nurse needs another bottle, which must be picked up in person in the hospital pharmacy. Which is the correct action by the nurse concerning this medication?
- A. ask the unit secretary to go to the pharmacy and pick it up
- B. send the unlicensed assistive personnel (UAP) to pick it up since the nurse is busy
- C. ask the client's health care provider to bring it when he or she rounds on the client
- D. ask another nurse to watch the clients while the nurse goes to the pharmacy to get the medication
Correct Answer: D
Rationale: The nurse must ensure continuous client monitoring, so asking another nurse to cover while retrieving the controlled medication is the safest action.