Nokea
The nurse is administering magnesium sulfate to a client experiencing severe preeclampsia. What intervention should the nurse implement during the administration of magnesium sulfate for this client?
- A. Schedule a daily ultrasound to assess fetal movement.
- B. Schedule a nonstress test every 4 hours to assess fetal well-being.
- C. Assess the client's temperature every 2 hours because the client is at high risk for infection.
- D. Assess for signs and symptoms of labor since the client's level of consciousness may be altered.
Correct Answer: D
Rationale: Magnesium sulfate is a central nervous system depressant and anticonvulsant. Because of the sedative effect of the magnesium sulfate, the client may not perceive labor. Daily ultrasounds are not necessary for this client. A nonstress test may be done, but not every 4 hours. This client is not at high risk for infection.
You may also like to solve these questions
The nurse is caring for a client who will be taught to ambulate with a cane. Before cane-assisted ambulation instructions begin, what should the nurse check for as the priority to assure client safety?
- A. A high level of stamina and energy
- B. Self-consciousness about using a cane
- C. Full range of motion in lower extremities
- D. Balance, muscle strength, and confidence
Correct Answer: D
Rationale: Assessing the client's balance, strength, and confidence helps determine if the cane is a suitable assistive device for the client. A high level of stamina and full range of motion are not needed for walking with a cane. Although body image (self-consciousness) is a component of the assessment, it is not the priority.
The ambulatory care nurse is assessing a client with chronic sinusitis. The nurse determines that which manifestations reported by the client are related to this problem? Select all that apply.
- A. Anosmia
- B. Chronic cough
- C. Blurry vision
- D. Nasal stuffiness
- E. Purulent nasal discharge
- F. Headache that worsens in the evening
Correct Answer: A,B,D,E
Rationale: Chronic sinusitis is characterized by anosmia (loss of smell), a chronic cough resulting from nasal discharge, nasal stuffiness, persistent purulent nasal discharge, and headache that is worse upon arising after sleep. Blurred vision is not associated directly to this condition.
A client is experiencing acute cardiac and cerebral symptoms as a result of an excess fluid volume. Which nursing measure should the nurse implement to increase the client's comfort until specific therapy is prescribed by the primary health care provider?
- A. Cover the client with warm blankets.
- B. Minimize visual and auditory stimuli present.
- C. Elevate the client's head to at least 45 degrees.
- D. Administer oxygen at 4 L per minute by nasal cannula.
Correct Answer: C
Rationale: Excess fluid volume can lead to symptoms such as shortness of breath and cerebral edema, which can be alleviated by elevating the head of the bed to at least 45 degrees to promote venous drainage and reduce intracranial pressure. This is a safe and effective nursing intervention to increase comfort until specific medical therapy is prescribed.
The nurse is preparing to initiate a bolus enteral feedings via nasogastric (NG) tube to a client. Which action represents safe practice by the nurse?
- A. Checking the volume of the residual after administering the bolus feeding
- B. Aspirating gastric contents before initiating the feeding to ensure that pH is greater than 9
- C. Elevating the head of the bed to 25 degrees and maintaining that position for 30 minutes after feeding
- D. Verifying correct nasogastric tube position with aspiration and administration of air bolus with auscultation
Correct Answer: D
Rationale: After initial radiographic confirmation of NG tube placement, methods used to verify nasogastric tube placement include measuring the length of the tube from the point it protrudes from the nose to the end, injecting 10 to 30 mL of air into the tube and auscultating over the left upper quadrant of the abdomen, and aspirating the secretions and checking to see if the pH is less than 3.5 (safest method). Residual should be assessed before administration of the next feeding. Fowler's position is recommended for bolus feedings, if permitted, and should be maintained for 1 hour after instillation.
The nurse instructs a preoperative client about the proper use of an incentive spirometer. What result should the nurse use to determine that the client is using the incentive spirometer effectively?
- A. Cloudy sputum
- B. Shallow breathing
- C. Unilateral wheezing
- D. Productive coughing
Correct Answer: D
Rationale: Incentive spirometry helps reduce atelectasis, open airways, stimulate coughing, and help mobilize secretions for expectoration, via vital client participation in recovery. Cloudy sputum, shallow breathing, and wheezing indicate that the incentive spirometry is not effective because they point to infection, counterproductive depth of breathing, and bronchoconstriction, respectively.