Nokea
The nurse is caring for a client receiving mechanical ventilation. The high-pressure alarm sounds. Which of the following actions should the nurse take FIRST?
- A. Check the tubing for kinks or obstructions.
- B. Suction the client's airway.
- C. Increase the oxygen concentration.
- D. Notify the respiratory therapist.
Correct Answer: A
Rationale: high-pressure alarms are often caused by obstructions such as kinks in the tubing or mucus in the airway
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A client who is a gravida 2, para 1 has been admitted for induction of labor with oxytocin (Pitocin).
It would be MOST important for the nurse to take which of the following actions?
- A. Mix Pitocin in D5W, begin at 5 mg/cc as primary IV to gravity flow.
- B. Decrease the rate/flow of Pitocin if the fetal heart rate is below 150.
- C. Piggyback the Pitocin into the mainline IV and maintain the flow by gravity.
- D. Start an IV line and piggyback the Pitocin with an infusion pump.
Correct Answer: D
Rationale: Strategy: The topic of the question is unstated. Read the answer choices for clues. (1) Pitocin should be a secondary infusion (2) normal range for fetal heart tones is 120 to 160 beats per minute (3) rate should be maintained by an infusion pump (4) correct-Pitocin should always be a secondary infusion controlled by an IV pump
Which of the following strategies would be MOST therapeutic as the nurse tries to analyze a bulimic client's eating habits and the circumstances that precipitate the client's eating problems?
- A. Observe family communication patterns at a 'monitored mealtime.'
- B. Distract the client at mealtime.
- C. Assign the client a food/feelings/thoughts/actions journal.
- D. Assign the client to write a 'lifeline' in relation to eating behaviors.
Correct Answer: C
Rationale: implementation, nurse is trying to analyze and understand what triggers the client's binging and purging activities, so therapeutic nursing intervention of assigning a thought/feelings/actions (T/F/A) journal relating to client's eating behaviors will be most helpful to the nurse and therapeutic to the client; after this information is gained and reviewed, collaboration by the nurse and client on other strategies such as delay and distraction techniques, stress reduction, and developing a 'lifeline' in relation to eating behaviors will further benefit the client
A client is transferred to the neurology unit after developing right-sided paralysis and aphasia. Which of the following should be included in the patient's plan of care?
- A. Encourage client to shake head in response to questions.
- B. Speak in a loud voice during interactions.
- C. Speak using phrases and short sentences.
- D. Encourage the use of radio to stimulate the client.
Correct Answer: C
Rationale: will decrease tension and anxiety; client may understand some of the incoming communication if it is kept simple; speech may be relearned with appropriate support and interventions
The nursing care plan for a five-year-old with a closed head injury should contain which of the following?
- A. Encourage child to sleep and decrease stimuli in the room.
- B. Assess orientation to person, place, and time every hour.
- C. Notify the physician regarding a negative Babinski reflex.
- D. Increase fluid intake to maintain adequate urinary output.
Correct Answer: B
Rationale: early signs of increased intracranial pressure are alterations in orientation
The nurse performs a routine IV tubing change on a 55-year-old woman with a central line. Fifteen minutes later, the nurse reenters the patient's room to find her cyanotic, short of breath, and complaining of pain. Her vital signs are BP 84/62, pulse 112, respirations 18.
What is the FIRST action the nurse should take?
- A. Call the physician to report the patient's symptoms.
- B. Lower the head of the bed and place the patient on her left side.
- C. Place the patient in high Fowler's position.
- D. Start oxygen at 4 L/min via nasal cannula.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) second action, first should respond to potential problem of emboli (2) correct-air will rise to right atrium, minimizes chance of air bubbles entering cerebral circulation (3) never done with shock, trapped air could travel to pulmonary circulation (4) not first action