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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.
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The nurse performs a neurovascular assessment on a client with a newly applied cast. The nurse should determine that there is a need for close observation and a need for follow-up if which is noted?
- A. Palpable pulses distal to the cast
- B. Capillary refill greater than 6 seconds
- C. Blanching of the nail bed when it is depressed
- D. Sensation when the area distal to the cast is pinched
Correct Answer: B
Rationale: To assess for adequate circulation, the nail bed of each finger or toe is depressed until it blanches, and then the pressure is released. This is known as capillary refill time. Optimally, the color will change from white to pink rapidly (less than 3 seconds). If this does not occur, the toes or fingers will require close observation and follow-up. Palpable pulses and sensations distal to the cast are expected. However, if pulses could not be palpated or if the client complained of numbness or tingling, the primary health care provider should be notified.
Tretinoin gel has been prescribed for a client with acne. What is the nurse's response when the client calls and reports that her skin has become very red and is beginning to peel?
- A. Discontinue the medication immediately.
- B. Come to the clinic immediately for an assessment.
- C. I'll notify your primary health care provider of these results.
- D. This is a normal occurrence with the use of this medication.
Correct Answer: D
Rationale: Tretinoin decreases cohesiveness of the epithelial cells, increasing cell mitosis and turnover. It is potentially irritating, particularly when used correctly. Within 48 hours of use, the skin generally becomes red and begins to peel. Options 1, 2, and 3 are incorrect statements to the client.
The nurse in an ambulatory care clinic takes a client's blood pressure (BP) in the left arm; it is 200/118 mm Hg. Which action should the nurse implement next?
- A. Notify the primary health care provider.
- B. Inquire about the presence of kidney disorders.
- C. Check the client's blood pressure in the right arm.
- D. Recheck the pressure in the same arm within 30 seconds.
Correct Answer: C
Rationale: When a high BP reading is noted, the nurse takes the pressure in the opposite arm to see if the blood pressure is elevated in one extremity only. The nurse would also recheck the blood pressure in the same arm but would wait at least 2 minutes between readings. The nurse would inquire about the presence of kidney disorders that could contribute to the elevated blood pressure. The nurse would notify the primary health care provider because immediate treatment may be required, but this would not be done without obtaining verification of the elevation.
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.
The nurse assessing the vital signs of a 3-year-old child hospitalized with a diagnosis of croup notes that the respiratory rate is 28 breaths per minute. Based on this finding, which nursing action is appropriate?
- A. Begin administering supplemental oxygen.
- B. Document the findings according to facility policies.
- C. Notify the child's primary health care provider immediately.
- D. Reassess the respiratory rate, rhythm, and depth in 15 minutes.
Correct Answer: B
Rationale: The normal respiratory rate for a 3-year-old child is approximately 20 to 30 breaths per minute. Because the respiratory rate is normal, options 1, 3, and 4 are unnecessary actions. The nurse would document the findings.