Nokea
The nurse is caring for a 22-year-old woman who is completing the first stage of labor. The woman's husband is at her side and has been coaching her according to exercises they learned at natural childbirth classes. Suddenly the woman begins to shake and screams, 'I can't stand this anymore!' The nurse should encourage the husband to
- A. instruct his wife to use shallow respirations during the contractions.
- B. offer his wife ice chips or sips of water to distract her from the pain.
- C. stroke his wife's abdomen between contractions.
- D. review with his wife the breathing pattern needed at each stage of labor.
Correct Answer: A
Rationale: entering transition phase of first stage of labor, slow shallow breaths needed (pant breathing)
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The home care nurse instructs the wife of a client about how to perform a wet-to-dry abdominal dressing for her husband with an infected abdominal incision. The nurse should intervene in which of the following situations?
- A. The wife wets the old dressing with sterile saline before removing it.
- B. The wife covers the wound with wet, sterile 4 × 4s.
- C. The wife irrigates the wound with hydrogen peroxide using a bulb syringe.
- D. The wife uses Montgomery straps to secure the dressing.
Correct Answer: A
Rationale: contraindicated, remove dry so wound debris and necrotic tissue are removed with old dressing
The nurse is caring for a patient hospitalized with an acute asthma attack. The nurse would be MOST concerned if which of the following was observed?
- A. The patient becomes more diaphoretic.
- B. The patient's respirations increase from 14 to 16 per minute.
- C. The patient's pulse increases from 86 to 100 beats per minute.
- D. The patient shows increasing pallor.
Correct Answer: C
Rationale: pulse increases due to decrease in oxygenation of tissues
The nurse is caring for a client who is receiving a continuous IV infusion of dopamine for hypotension. Which of the following findings would be of GREATest concern to the nurse?
- A. Heart rate of 100 bpm.
- B. Blood pressure of 90/60 mmHg.
- C. Urine output of 20 mL/hour.
- D. Respiratory rate of 18 breaths/min.
Correct Answer: C
Rationale: Urine output of 20 mL/hour indicates oliguria, a serious complication of dopamine, suggesting inadequate renal perfusion despite treatment for hypotension. Options A, B, and D are less concerning: heart rate 100 bpm and blood pressure 90/60 mmHg are expected, and respiratory rate 18 breaths/min is normal.
The nurse observes a student nurse checking the placement of a nasogastric (NG) tube. Which of the following actions, if performed by the student nurse, would require an intervention by the nurse?
- A. Places the end of the NG tube in a cup of water and watches for bubble formation.
- B. Checks the pH of the contents aspirated from the NG tube.
- C. Positions a stethoscope on the upper abdomen and listens as air is introduced into the NG tube.
- D. Uses a large barreled syringe to aspirate for stomach contents.
Correct Answer: A
Rationale: not considered acceptable procedure
The nurse is supervising a student nurse teach a client about a newly prescribed medication. Which of the following actions, if observed by the nurse, would require an intervention?
- A. The student nurse glances at his/her watch when instructing the client.
- B. The student nurse uses culturally appropriate language and teaching materials.
- C. The student nurse begins instructions to the client discussing information that concerns the client.
- D. The student nurse chooses a time for teaching when there are no visitors.
Correct Answer: A
Rationale: lack of attending behaviors are always a barrier to learning