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The nurse is caring for a client who is scheduled an arthrogram involving the use of a contrast medium. Which action by the nurse is the priority?
- A. Determining the presence of client allergies
- B. Asking if the client has any last-minute questions
- C. Telling the client to try to void before leaving the unit
- D. Emphasizing to the client the importance of remaining still during the procedure
Correct Answer: A
Rationale: Because of the risk of allergy to contrast medium, the nurse places the highest priority on assessing whether the client has an allergy to iodine or shellfish. The nurse also reinforces information about the test and reminds the client about the need to remain still during the procedure. It is helpful to have the client void before the procedure for comfort.
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A client in the late, active, first stage of labor has just reported a gush of vaginal fluid. The nurse observes a fetal monitor pattern of variable decelerations during contractions followed by a brief acceleration. After that, there is a return to baseline until the next contraction, when the pattern is repeated. On the basis of these data, what is the nurse's initial intervention?
- A. Take the client's vital signs.
- B. Perform a Leopold's maneuver.
- C. Perform a manual sterile vaginal exam.
- D. Test the vaginal fluid with a Nitrazine strip.
Correct Answer: C
Rationale: Variable deceleration with brief acceleration after a gush of amniotic fluid is a common clinical manifestation of cord compression caused by occult or frank prolapse of the umbilical cord. A manual vaginal exam can detect the presence of the cord in the vagina, which confirms the problem. On the basis of the data in the question, none of the remaining options are initial actions.
The nurse prepares for a client in leg traction to be admitted to the nursing unit. The nurse asks the unlicensed assistive personnel to obtain which essential item that will be needed to assist the client to move in bed while in leg traction?
- A. A foot board
- B. Extra pillows
- C. A bed trapeze
- D. An electric bed
Correct Answer: C
Rationale: A trapeze is essential to allow the client to lift straight up while being moved so that the amount of pull exerted on the limb in traction is not altered. A foot board and extra pillows do not facilitate moving. Either an electric bed or a manual bed can be used for traction, but this does not specifically assist the client with moving in bed.
The nurse is asked to assist another health care team member with providing care for a client. On entering the client's room, the nurse notes that the client is placed in this position (refer to figure). After maintaining the client position, what should the nurse interpret that this client is most likely being treated for?
- A. Shock
- B. A head injury
- C. Respiratory insufficiency
- D. Increased intracranial pressure
Correct Answer: A
Rationale: A client in shock is placed in a modified Trendelenburg's position that includes elevating the legs, leaving the trunk flat, and elevating the head and shoulders slightly. This position promotes increased venous return from the lower extremities without compressing the abdominal organs against the diaphragm. The Trendelenburg position is no longer recommended for hypotensive clients because the client is predisposed to aspiration and worsens gas exchange. The remaining options identify conditions in which the head of the client's bed would be elevated.
The nurse needs to administer 7.5 mg of a medication intramuscularly. The medication label reads '10 mg/mL.' How much medication should the nurse prepare to administer? Fill in the blank.
Correct Answer: 0.75
Rationale: Use the following formula to calculate the medication dose: Desired / Available × Volume = mL per dose. 7.5 mg / 10 mg × 1 mL = 0.75 mL.
The nurse is checking the fundus of a postpartum woman and notes that the uterus is soft and spongy. Which nursing action is appropriate initially?
- A. Encourage the mother to ambulate.
- B. Notify the primary health care provider.
- C. Massage the fundus gently until it is firm.
- D. Document fundal position, consistency, and height.
Correct Answer: C
Rationale: If the fundus is boggy (soft), it should be massaged gently until it is firm and the client is observed for increased bleeding or clots. Option 1 is an inappropriate action at this time. The nurse should document the fundal position, consistency, and height; the need to perform fundal massage; and the client's response to the intervention. The primary health care provider will need to be notified if uterine massage is not helpful.