Nokea
The nurse is caring for a client with a closed head injury. Which finding should be reported to the doctor immediately?
- A. Urine output of 50 mL per hour
- B. Blood pressure of 148/92
- C. Respiratory rate of 16 breaths per minute
- D. Pupils that are unequal
Correct Answer: D
Rationale: Unequal pupils suggest increased intracranial pressure or neurological deterioration in a head injury, requiring immediate reporting. The other findings are within normal or less urgent ranges.
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The client has been in active labor for the last 12 hours. During the last 3 hours, labor has been augmented with oxytocin because of hypoactive uterine contractions. Her physician assesses her cervix as 95% effaced, 8 cm dilated, and the fetus is at 0 station. Her oral temperature is 100.2F at this time. The physician orders that she be prepared for a cesarean delivery. In preparing the client for the cesarean delivery, which one of the following physician's orders should the RN question?
- A. Administer meperidine (Demerol) 100 mg IM 1 hour prior to the delivery.
- B. Discontinue the oxytocin infusion.
- C. Insert an indwelling Foley catheter prior to delivery.
- D. Prepare abdominal area from below the nipples to below the symphysis pubis area.
Correct Answer: A
Rationale: Meperidine crosses the placental barrier and can cause respiratory depression in the fetus, making it inappropriate for preoperative cesarean delivery.
The physician has ordered intravenous fluid with potassium for a client admitted with gastroenteritis and dehydration. Before adding potassium to the intravenous fluid, the nurse should:
- A. Assess the urinary output.
- B. Obtain arterial blood gases.
- C. Perform a dextrostick.
- D. Obtain a stool culture.
Correct Answer: A
Rationale: Potassium supplementation requires adequate renal function to prevent hyperkalemia. Assessing urinary output ensures the kidneys are functioning before adding potassium.
A client who uses a respiratory inhaler asks the nurse to explain how he can know when half his medication is empty so that he can refill his prescription. The nurse should tell the client to:
- A. Shake the inhaler and listen for the contents.
- B. Drop the inhaler in water to see if it floats.
- C. Check for a hissing sound as the inhaler is used.
- D. Press the inhaler and watch for the mist.
Correct Answer: B
Rationale: Dropping the inhaler in water to see if it floats is a practical way to estimate remaining medication; a half-empty inhaler will float, while a full one sinks.
During an examination, the nurse notes that an infant has diaper rash on the convex surfaces of his buttocks, inner thighs, and scrotum. Which of the following nursing interventions will be most effective in resolving the condition?
- A. Coating the inflamed areas with zinc oxide
- B. Using talcum powder on the inflamed areas to promote drying
- C. Removing the diaper entirely for extended periods of time
- D. Cleaning the inflamed area thoroughly with disposable wet 'wipes' at each diaper change
Correct Answer: C
Rationale: Removing the diaper and exposing the area to air and light facilitate drying and healing, effectively resolving diaper rash.
The nurse is assessing a client following the removal of a pituitary tumor. The nurse notes that the urinary output has increased and that the urine is very dilute. The nurse should give priority to:
- A. Notifying the doctor immediately
- B. Documenting the finding in the chart
- C. Decreasing the rate of IV fluids
- D. Administering vasopressive medication
Correct Answer: A
Rationale: Increased, dilute urine post-pituitary surgery suggests diabetes insipidus due to decreased antidiuretic hormone, requiring immediate physician notification.