Nokea
The nurse is caring for a laboring client who is on an oxytocin infusion. The client experiences seven contractions in a 10-minute time period. The fetal heart rate tracing is a category III. Which action should the nurse take?
- A. discontinue the oxytocin infusion
- B. increase the oxytocin infusion rate
- C. decrease the oxytocin infusion rate by half
- D. reposition the client into a high-Fowler's position
Correct Answer: A
Rationale: A category III fetal heart rate tracing indicates fetal distress, and seven contractions in 10 minutes suggest uterine hyperstimulation. Discontinuing oxytocin is the priority to reduce fetal stress.
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A client has recurrent episodes of constipation and fecal impaction. The nurse is assisting the client with a bowel-training regimen. Which of the following interventions should be included? Select all that apply.
- A. Scheduled toileting
- B. Stool softeners
- C. High-fiber diet
- D. Daily laxatives
- E. Periodic enemas
- F. Routine exercise
Correct Answer: A,B,C,F
Rationale: Bowel training includes scheduled toileting (A), stool softeners (B), high-fiber diet (C), and routine exercise (F) to promote regular bowel movements. Daily laxatives (D) and periodic enemas (E) are not preferred long-term.
Which of the following are true statements regarding peripherally inserted central catheter (PICC) lines? Select all that apply.
- A. requires sterile technique during insertion
- B. can be inserted by any LPN or RN
- C. lower risk of infection compared to other central lines
- D. increased risk of pneumothorax
- E. can be inserted at the patient bedside
Correct Answer: A,C,E
Rationale: PICC lines require sterile technique, have a lower infection risk than other central lines, and can be inserted at the bedside. Only specially trained RNs (not any LPN/RN) can insert them, and pneumothorax risk is minimal.
A client who is to undergo electroconvulsive therapy for severe depression is quite anxious about the treatment and asks the nurse what to expect after treatment. Which of the following information should the nurse include? Select all that apply.
- A. The client will experience confusion for a short time.
- B. Headache and muscle soreness are common.
- C. Some degree of memory loss, usually transient, may occur.
- D. Possible urinary incontinence may occur for 12 hours.
- E. The client may experience hallucinations for 2 to 3 weeks.
Correct Answer: A,B,C
Rationale: ECT causes short-term confusion (A), headache/muscle soreness (B), and transient memory loss (C). Incontinence (D) and prolonged hallucinations (E) are not typical.
The nurse is conducting a physical assessment on a client with anemia. Which of the following clinical manifestations would be most indicative of the anemia?
- A. BP 146/88
- B. Respirations 28 shallow
- C. Weight gain of 10 pounds in 6 months
- D. Pink complexion
Correct Answer: B
Rationale: Tachypnea (respirations 28 shallow) is a common sign of anemia due to reduced oxygen-carrying capacity, prompting compensatory increased respiratory rate.
Which of the following is a correctly stated nursing diagnosis for a client with abruptio placentae?
- A. Infection related to obstetrical trauma.
- B. Potential for fetal injury related to abruptio placentae.
- C. Potential alteration in tissue perfusion related to depletion of fibrinogen.
- D. Fluid volume deficit related to bleeding.
Correct Answer: D
Rationale: abruptio placenta is premature separation of a normally implanted placenta leading to hemorrhage; fluid volume deficit is a major nursing concern with these clients