Nokea
The nurse is caring for an organ donor client with a severe head injury from an MVA. Which of the following is most important when caring for the organ donor client?
- A. Maintenance of the BP at 90 mmHg or greater
- B. Maintenance of a normal temperature
- C. Keeping the hematocrit at less than 28%
- D. Ensuring a urinary output of at least 300 mL/hr
Correct Answer: A
Rationale: Maintaining BP at 90 mmHg or greater ensures organ perfusion, critical for organ viability in a donor. Normal temperature and adequate urine output are important, but BP is the priority. Low hematocrit is not a goal.
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The nurse is reviewing a new client's medication orders. Which order would prompt the nurse to notify the health care provider?
- A. allopurinol 300 mg PO daily
- B. potassium chloride 20 mEq PO daily
- C. warfarin (Coumadin) 50 mg PO daily
- D. metoprolol (Lopressor) 50 mg PO daily
Correct Answer: C
Rationale: A 50 mg dose of warfarin is unusually high and likely a dosing error, requiring provider clarification. Other orders are within typical ranges.
A patient is admitted to the surgical unit with a diagnosis of rule out intestinal obstruction. The nurse is preparing to insert a Salem sump NG tube as ordered. In which of the following positions would it be BEST for the nurse to place this patient during the procedure?
- A. Head of bed elevated 30°-45°.
- B. Head of bed elevated 60°-90°.
- C. Side-lying with head elevated 15°.
- D. Lying flat with head turned to the left side.
Correct Answer: B
Rationale: facilitates swallowing and movement of tube through GI tract
A client with sickle cell anemia is admitted to the labor and delivery unit during the first phase of labor. The nurse should anticipate the client's need for:
- A. Supplemental oxygen
- B. Fluid restriction
- C. Blood transfusion
- D. Delivery by Caesarean section
Correct Answer: A
Rationale: Sickle cell anemia increases oxygen demand during labor, often requiring supplemental oxygen.
A client has had 4 pregnancies. She experienced one miscarriage at 12 weeks, had one stillborn birth at 34 weeks, a healthy son at 38 weeks, and a healthy daughter at 40 weeks. How would the client's obstetric history be classified?
- A. Gravida 3, Para 2
- B. Gravida 4, Para 4
- C. Gravida 4, Para 3
- D. Gravida 4, Para 2
Correct Answer: D
Rationale: Gravida 4 (4 pregnancies), Para 2 (2 viable births at 38 and 40 weeks). Miscarriage and stillbirth count as pregnancies but not viable births.
One week after discharge of a postpartum client, the client's husband calls the postpartum unit and asks the nurse, 'Is it normal for my wife to cry at the drop of a hat? I'm worried I've done something to upset her.' The nurse's best initial response would be:
- A. Have you noticed any pattern to her periods of crying?
- B. Try not to worry about it. I'm sure it's just the postpartum blues.
- C. Can you think of something you might have done to upset her?
- D. Let's consider some of the ways you can decrease her depression.
Correct Answer: B
Rationale: Postpartum blues are common within the first two weeks, characterized by emotional lability. Reassuring the husband while acknowledging the normalcy of this condition is appropriate.