Nokea
The nurse is working on a birthing unit that has several unlicensed assistive personnel (UAP). The nurse determines that the UAP understands the type of information to report to the nurse when the UAP reports which of the following about one of the clients?
- A. An episode of nausea after administration of an epidural anesthetic.
- B. Contractions 3 minutes apart and lasting 40 seconds.
- C. Scream of spontaneous rupture of the membranes.
- D. Sleeping after administration of I.V. nalbuphine (Nubain).
Correct Answer: A,C
Rationale: Nausea after an epidural and spontaneous rupture of membranes are significant events requiring nurse assessment due to potential complications. Contractions and sleeping are expected findings.
You may also like to solve these questions
A client who underwent cardiac surgery 2 days ago is recovering well. His wife, who is assisting with his care, says, 'He is doing too much. I told him to let me help, but he won't let me.' The nurse says to the wife, 'It sounds like you need to feel you can be more helpful to him.' In order to make her nonverbal behavior complement her words, the nurse should:
- A. Direct the eyes at the client.
- B. Direct the body and eyes at the wife and client.
- C. Avoid direct eye contact with the client and wife.
- D. Shift the eyes back and forth between the client and wife.
Correct Answer: B
Rationale: Directing body and eyes to both the wife and client shows engagement and inclusivity, complementing the empathetic verbal response.
Which question is asked more than any other root cause analysis activity?
- A. What?
- B. Why?
- C. Who?
- D. When?
Correct Answer: B
Rationale: The 'Why?' question is central to root cause analysis, as it drives the investigation into the underlying causes of an event through techniques like the '5 Whys.'
Buspirone hydrochloride is prescribed for a client diagnosed with an anxiety disorder. The nurse providing instructions should inform the client about which characteristic of this medication?
- A. There is risk of addiction.
- B. Dizziness and nausea may occur.
- C. Tolerance can occur with the medication.
- D. The medication can produce a sedating effect.
Correct Answer: B
Rationale: Buspirone hydrochloride is used in the management of anxiety disorders. The medication has a more favorable side effect profile than do the benzodiazepines. Dizziness, nausea, headaches, lightheadedness, and paradoxical central nervous system excitement, which generally are not major problems, are side effects of the medication. The advantages of this medication are that it is not addicting, tolerance does not develop, and it is not sedating.
A client with a history of Addison's disease is prescribed hydrocortisone. Which instruction should the nurse include?
- A. Take it on an empty stomach
- B. Double the dose during stress
- C. Stop it if weight gain occurs
- D. Take it at bedtime only
Correct Answer: B
Rationale: Doubling hydrocortisone during stress (e.g., illness) prevents adrenal crisis in Addison's disease, mimicking the body's natural cortisol response.
A 24-year-old nulligravid client with a history of irregular menstrual cycles visits the clinic because she suspects that she is 'about 6 weeks pregnant.' An ultrasound is scheduled in 2 weeks. The nurse should instruct the client that this test will be done to:
- A. Assess gestational age.
- B. Determine a multifetal pregnancy.
- C. Identify the gender of the fetus.
- D. Assess of maternal pelvic adequacy.
Correct Answer: A
Rationale: An early ultrasound at around 8 weeks is primarily used to confirm gestational age and viability.