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The nurse in charge of the labor and delivery department is making the client assignments for the day. Which client should the most experienced nurse receive?
- A. A 40-week pregnant client attached to the fetal monitor having late decelerations.
- B. A 39-week pregnant client in labor with contractions 3 minutes apart.
- C. A 33-week pregnant client with triplets who is on bed rest.
- D. A 26-week pregnant client who is having Braxton Hicks contractions.
Correct Answer: A
Rationale: Late decelerations at 40 weeks (A) indicate fetal distress, requiring the most experienced nurse for close monitoring and potential intervention. Active labor (B), preterm triplets (C), and Braxton Hicks (D) are less critical or stable, suitable for less experienced staff.
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The client has just been given an IV dose of morphine 6 mg for neuropathic pain. A few minutes later, the nurse notes that the client's respirations are now 8, and his blood pressure has dropped from 122/83 mmHg to 88/67 mmHg. Which nursing action is the most appropriate?
- A. Prepare for intubation.
- B. Prepare to administer a dopamine infusion.
- C. Administer naloxone.
- D. Start an IV infusion of normal saline.
Correct Answer: C
Rationale: Respiratory depression (RR 8) and hypotension post-morphine (C) indicate opioid overdose, requiring naloxone to reverse effects, per ACLS guidelines. Intubation (A), dopamine (B), and saline (D) are secondary or inappropriate without reversal.
The nurse is triaging a client involved in a chemical spill at a local chemical plant. The nurse assesses the client as responsive but unable to walk, with a respiratory rate of 28 and capillary refill <2 seconds. It would be correct for the nurse to triage this client with a
- A. yellow tag.
- B. red tag.
- C. black tag.
- D. green tag.
Correct Answer: A
Rationale: A yellow tag (A) is appropriate for a responsive client unable to walk with stable vital signs (RR 28, capillary refill <2 sec), indicating urgent but not immediate life-threatening needs. Red (B) is for critical, black (C) for deceased, and green (D) for minor injuries.
The nurse is participating in a quality improvement project to reduce urinary tract infections (UTIs) for older adult clients in long-term care. It would be appropriate for the nurse to recommend Select all that apply.
- A. the addition of more liquids to meal trays.
- B. standardizing the dosing times of prescribed diuretics.
- C. audio reminders for turning bed-bound clients.
- D. daily bathing using bath basins.
- E. a staff in-service on hand hygiene.
Correct Answer: A, E
Rationale: Increasing liquids (A) reduces UTI risk by promoting urination, and hand hygiene in-service (E) prevents infection spread. Diuretic timing (B) is unrelated, turning reminders (C) address pressure ulcers, and bath basins (D) may increase infection risk.
The nurse is reviewing tasks for assigned clients. Which action is a priority to implement?
- A. Visual acuity test for a client reporting blurred vision in one eye.
- B. 12-lead electrocardiogram for a client reporting chest pain.
- C. Orthostatic vital signs for a client complaining of syncope.
- D. Discharge teaching for a client newly diagnosed with hypertension.
Correct Answer: B
Rationale: A 12-lead ECG for chest pain (B) is the priority to rule out life-threatening cardiac events like myocardial infarction. Blurred vision (A), syncope (C), and discharge teaching (D) are less urgent, as they are not immediately life-threatening.
The nurse is caring for a client who is postoperative following a lobectomy. The client is receiving fentanyl via an epidural. The nurse should monitor the client for which complication?
- A. Diarrhea
- B. Hypotension
- C. Hyperventilation
- D. Urinary incontinence
Correct Answer: B
Rationale: Epidural fentanyl can cause hypotension (B) due to vasodilation, a serious complication requiring monitoring. Diarrhea (A), hyperventilation (C), and urinary incontinence (D) are less common or unrelated.