Nokea
The nurse assesses a prolonged deceleration of the fetal heart rate while the client is receiving oxytocin IV to stimulate labor. The priority nursing intervention would be to
- A. discontinue the infusion.
- B. turn client to the left side.
- C. change the fluids to LR.
- D. increase the IV flow rate.
Correct Answer: A
Rationale: will decrease contractions and thus possibly remove uterine pressure to the fetus, which is possibly cause of deceleration
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The nurse teaches a group of boy scouts how to prevent Lyme disease. Which of the following statements, if made by one of the boy scouts to the nurse, would indicate that further teaching is necessary?
- A. When I go on a long hike, I should check any exposed skin for insects every four hours.
- B. When I hike in the woods, I should wear long pants, socks, and a long-sleeved shirt.
- C. I should remove any ticks by crushing them firmly against the skin.
- D. I should reapply insect repellant every couple of hours when hiking.
Correct Answer: C
Rationale: should not be crushed, remove tick with tweezers or fingers and flush down toilet; burning a tick could spread infection
The nurse is preparing a patient for an 8:00 AM outpatient electroconvulsive (ECT) treatment. Which of the following questions is the MOST important for the nurse to ask?
- A. Did you have anything to eat or drink before you came in today?
- B. Have you had any headaches since your last treatment?
- C. Who came with you to the hospital today?
- D. Have you had much memory loss since you began your treatments?
Correct Answer: A
Rationale: client given general anesthesia for ECT; NPO after midnight
The nurse is teaching a client with newly diagnosed diabetes mellitus how to treat hypoglycemia at home. The nurse should instruct the client to do which of the following actions if symptoms of hypoglycemia are experienced?
- A. Eat a candy bar.
- B. Drink ½-cup fruit juice followed by a protein snack.
- C. Inject 10 units of Humulin R.
- D. Inject glucagon.
Correct Answer: B
Rationale: will correct hypoglycemia and stabilize blood sugar
At approximately 6 PM, the nurse begins to open the nurses' notes for the evening shift. The last entry is noted for 1 PM, and there is no signature. The MOST appropriate nursing response is to
- A. leave approximately three or four lines for the day nurse to enter the day information and sign the chart.
- B. review with the client the activities after 1 PM, and enter what are determined to be the activities after 1 PM.
- C. begin charting on the next line below the last entry, and make a note for the day nurse to make a late entry to complete the chart.
- D. do not enter anything until the day nurse has been notified of the problem and returns to the unit to complete charting.
Correct Answer: C
Rationale: day nurse can make a 'late entry' to add any additional information
A nurse discusses changes due to aging with a group at the senior citizen center. The nurse knows that which of the following changes in the pattern of urinary elimination normally occur with aging?
- A. Decreased frequency.
- B. Incontinence.
- C. Sphincter reflexes decrease.
- D. Formation of bladder stones.
Correct Answer: B
Rationale: ureters, bladder, and urethra lose muscle tone results in stress and urge incontinence