Nokea
The nurse, caring for a client in the active stage of labor, is monitoring the fetal status and notes that the monitor strip shows a late deceleration. Based on this observation, which action should the nurse plan to take immediately?
- A. Document the findings.
- B. Prepare for immediate birth.
- C. Increase the rate of an oxytocin infusion.
- D. Administer oxygen to the client via face mask.
Correct Answer: D
Rationale: Late decelerations are caused by uteroplacental insufficiency as the result of decreased blood flow and oxygen transfer to the fetus through the intervillous space during the uterine contractions. This causes hypoxemia; therefore, oxygen is necessary. Although the finding needs to be documented, documentation is not the priority action in this situation. Late decelerations are considered an ominous sign but do not necessarily require immediate birth of the baby. The oxytocin infusion should be discontinued when a late deceleration is noted. The oxytocin would cause further hypoxemia because the medication stimulates contractions and leads to increased uteroplacental insufficiency.
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The nurse reviews the client's vital signs in the client's chart. Based on these data findings, what is the client's pulse pressure? Fill in the blank.
Correct Answer: 74 mm Hg
Rationale: The difference between the systolic and diastolic blood pressure is the pulse pressure. Therefore, if the client has a blood pressure of 146/72 mm Hg, then the pulse pressure is 74.
A client with a spinal cord injury is at risk of developing footdrop. What intervention should the nurse use as a preventive measure?
- A. Mole skin-lined heel protectors
- B. Regular use of posterior splints
- C. Application of pneumatic boots
- D. Avoiding dorsal flexion of the foot
Correct Answer: B
Rationale: The effective means of preventing footdrop (plantar flexion) is the use of posterior splints or high-top sneakers. Dorsal flexing of the foot would help to counteract the effects of footdrop. Heel protectors protect the skin but do not prevent footdrop. Pneumatic boots prevent deep vein thrombosis but not footdrop.
The nurse has a prescription to administer hydroxyzine to a client by the intramuscular route. Before administering the medication, what information should the nurse share with the client?
- A. Excessive salivation is a side effect.
- B. There will be some pain at the injection site.
- C. There should be relief from nausea within 5 minutes.
- D. The client may experience increased agitation for about 2 hours.
Correct Answer: B
Rationale: Hydroxyzine is an antiemetic and sedative/hypnotic that may be used in conjunction with opioid analgesics for added effect. The injection can be painful. Hydroxyzine causes dry mouth and drowsiness as side effects. Agitation is not a usual side effect. Medications administered by the intramuscular route generally take 20 to 30 minutes to become effective.
The nurse admitting a client diagnosed with myocardial infarction (MI) to the coronary care unit (CCU) should plan care by implementing which intervention?
- A. Beginning thrombolytic therapy
- B. Placing the client on continuous cardiac monitoring
- C. Infusing intravenous (IV) fluid at a rate of 150 mL per hour
- D. Administering oxygen at a rate of 6 L per minute by nasal cannula
Correct Answer: B
Rationale: Standard interventions upon admittance to the CCU as they relate to this question include continuous cardiac monitoring. Thrombolytic therapy may or may not be prescribed by the primary health care provider. Thrombolytic agents are most effective if administered within the first 6 hours of the coronary event. The nurse should ensure that there is an adequate IV line insertion of an intermittent lock. If an IV infusion is administered, it is maintained at a keep-vein-open rate to prevent fluid overload and heart failure. Oxygen should be administered at a rate of 2 to 4 L per minute unless otherwise prescribed.
A client who has been diagnosed with carbon monoxide poisoning is asking that the oxygen mask be removed. The nurse shares with the client that the oxygen may be safely removed once the carboxyhemoglobin level decreases to less than which level?
- A. 5%
- B. 10%
- C. 15%
- D. 25%
Correct Answer: A
Rationale: Oxygen may be removed safely from the client with carbon monoxide poisoning once carboxyhemoglobin levels are less than 5%. Normal carboxyhemoglobin (HbCO) levels are 0% to 3% for nonsmokers and 3% to 8% for smokers. Levels of 10% to 20% cause headaches, nausea, vomiting, and dyspnea. Levels of 30% to 40% cause severe headaches, syncope, and tachydysrhythmias. Levels greater than 40% cause Cheyne-Stokes respiration or respiratory failure, seizures, unconsciousness, permanent brain damage, cardiac arrest, and even death. Options 2, 3, and 4 are elevated levels.