Nokea
The nurse is caring for a 27-year-old client in active labor. After reviewing the fetal heart tone strip shown, the nurse should take which action first?
- A. reposition the client
- B. draw a potassium level
- C. notify the health care provider
- D. prepare the client for a cesarean section
Correct Answer: A
Rationale: Repositioning the client is the first step to improve fetal oxygenation if the fetal heart tone strip shows distress, as it is non-invasive and may resolve the issue.
You may also like to solve these questions
The nurse is assisting a client with diverticulitis to select appropriate foods. Which food should be avoided?
- A. Bran
- B. Fresh peach
- C. Tomato and cucumber salad
- D. Dinner roll
Correct Answer: C
Rationale: Clients with diverticulitis should avoid foods with seeds, such as tomatoes and cucumbers, as they can irritate diverticula. Bran, peaches, and dinner rolls are generally safe.
During a unit card game, a client with acute mania begins to sing loudly as she starts to undress. The nurse should:
- A. Ignore the client's behavior
- B. Exchange the cards for a checker board
- C. Send the other clients to their rooms
- D. Cover the client and walk her to her room
Correct Answer: D
Rationale: Covering the client and escorting her to a private area maintains dignity and safety, addressing the inappropriate behavior calmly.
A nurse is working in an endoscopy recovery area. Many of the clients are administered midazolam (Versed) to provide conscious sedation. Which medication is important to have available as an antidote for Versed?
- A. Diazepam (Valium)
- B. Naloxone (Narcan)
- C. Flumazenil (Romazicon)
- D. Florinef (Fludrocortisone)
Correct Answer: C
Rationale: Flumazenil (Romazicon) is the antidote for benzodiazepines like midazolam, reversing sedation or overdose. Naloxone is for opioids, and the others are unrelated.
A client with obsessive compulsive personality disorder annoys his coworkers with his rigid-perfectionistic attitude and his preoccupation with trivial details. An important nursing intervention for this client would be:
- A. Helping the client develop a plan for changing his behavior
- B. Contracting with him for the time he spends on a task
- C. Avoiding a discussion of his annoying behavior because it will only make him worse
- D. Encouraging him to set a time schedule and deadlines for himself
Correct Answer: D
Rationale: Setting a time schedule helps the client manage perfectionistic tendencies by structuring tasks, reducing preoccupation with trivial details.
A client had a total thyroidectomy yesterday. The client is complaining of tingling around the mouth and in the fingers and toes. What would the nurses' next action be?
- A. Obtain a crash cart
- B. Check the calcium level
- C. Assess the dressing for drainage
- D. Assess the blood pressure for hypertension
Correct Answer: B
Rationale: Tingling around the mouth and extremities suggests hypocalcemia, a common complication post-thyroidectomy due to parathyroid gland disturbance, so checking the calcium level is the next action.