Nokea
A 28-year-old woman at 39-weeks gestation in active labor screams, 'I have to push, I have to push.' The nurse notes that the client is 8 cm dilated.
The nurse should
- A. instruct the client to take a deep breath and bear down.
- B. apply gentle but firm fundal pressure to the client's abdomen.
- C. coach the client in relaxation techniques.
- D. tell the client to pant with pursed lips.
Correct Answer: D
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) pushing should be discouraged until the second stage of labor (2) would increase discomfort (3) is inappropriate at this time; this is a short, intense period of labor (4) correct-describes transition phase of labor, breathing technique allows patient to control pain and urge to push and promotes adequate oxygenation of fetus
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The doctor has ordered chlorpromazine (Thorazine) to control an alcoholic client's restlessness, agitation, and irritability following surgery. The nurse should check the order with the doctor based on which of the following rationales?
- A. The nurse believes that the client's symptoms reflect alcohol withdrawal.
- B. The nurse does not know if the client is allergic to this medication.
- C. The nurse knows that the client is not psychotic.
- D. The nurse routinely checks on the doctor's orders.
Correct Answer: A
Rationale: medication is contraindicated for the treatment of alcohol withdrawal symptoms; medication will lower client's seizure threshold and BP, causing potentially serious medical consequences
A low-sodium, high-potassium diet is ordered for a client. Which food selection made by the client indicates understanding of the prescribed diet?
- A. Orange juice, baked chicken, and a cucumber and tomato salad
- B. Milk, roast beef, and spinach salad
- C. Iced tea, fish sandwich, and mixed vegetables
- D. Cola, fried shrimp, and coleslaw
Correct Answer: A
Rationale: Orange juice and vegetables are high in potassium and low in sodium, aligning with the prescribed diet, unlike milk, beef, or fried foods.
A Miller-Abbott tube is ordered for a client. The nurse knows that the main reason this tube is inserted is to
- A. provide an avenue for nutrients to flow past an obstructed area.
- B. prevent fluid and gas accumulation in the stomach.
- C. administer drugs that can be absorbed directly from the inTest inal mucosa.
- D. remove fluid and gas from the small inTest ine.
Correct Answer: D
Rationale: Miller-Abbott tube provides for inTest inal decompression; inTest inal tube is often used for treatment of paralytic ileus
After abdominal surgery, a client is admitted from the recovery room with intravenous fluid infusing at 100 cc/h. One hour later, the nurse finds the clamp wide open and notes that the client has received 850 cc.
The nurse would be MOST concerned by which of the following?
- A. A CVP reading of 12 and bradycardia.
- B. Tachycardia and hypotension.
- C. Dyspnea and oliguria.
- D. Rales and tachycardia.
Correct Answer: D
Rationale: Strategy: 'MOST concerned' indicates a complication. (1) CVP is normal, and bradycardia is incorrect (2) does not contain information relevant to fluid overload (3) does not contain information relevant to fluid overload (4) correct-indicate cardiovascular fluid overload
The nurse is caring for a client who is postoperative day 1 after a pancreaticoduodenectomy (Whipple procedure). Which of the following findings would be of GREATest concern to the nurse?
- A. Temperature of 100.8°F (38.2°C).
- B. Pain at the incision site.
- C. Nasogastric tube output of 200 mL.
- D. Urine output of 40 mL/hour.
Correct Answer: A
Rationale: A temperature of 100.8°F suggests infection, a serious complication post-Whipple procedure due to extensive surgery, requiring immediate evaluation. Options B, C, and D are expected: incision pain, NG tube output, and urine output 40 mL/hour are normal on day 1.