Nokea
The nurse should monitor the client for which of the following complications?
- A. Contractions
- B. Hypertension
- C. Epigastric pain
- D. Vomiting
Correct Answer: A
Rationale: Contractions can indicate preterm labor, a potential complication after amniocentesis.
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Which of the following examples should the nurse include in the teaching as an example of malpractice?
- A. Documenting communication with a provider in the progress notes of the client's medical record
- B. Placing a yellow bracelet on a client who is at risk for falls
- C. Leaving a nasogastric tube clamped after administering oral medication
- D. Administering potassium via IV bolus
Correct Answer: C
Rationale: The correct answer is C because leaving a nasogastric tube clamped after administering oral medication is an example of malpractice. This action can lead to obstruction and potential harm to the client. Documenting communication (A) is a standard practice to ensure accurate record-keeping. Placing a yellow bracelet (B) is a safety measure. Administering potassium via IV bolus (D) is within the scope of practice if done correctly.
A nurse is caring for a client who requires seclusion to prevent harm to others on the unit. Which of the following is an appropriate action for the nurse to take?
- A. Document the client's behavior prior to being placed in seclusion,
- B. Assess the client's behavior once every hour
- C. Offer fluids every 2 hr.
- D. Discuss with the client his inappropriate behavior prior to seclusion
Correct Answer: A
Rationale: The correct answer is A: Document the client's behavior prior to being placed in seclusion. This is important for legal and clinical reasons as it provides a clear record of the client's behavior leading up to seclusion, ensuring transparency and accountability. Assessing behavior once every hour (choice B) may not be sufficient for monitoring the client's condition in seclusion. Offering fluids every 2 hours (choice C) is important for hydration but not directly related to seclusion. Discussing inappropriate behavior with the client (choice D) may escalate the situation and is not recommended in this scenario.
A nurse is developing a care plan for a client who is in Buck's traction and is scheduled for surgery for a fractured femur of the right leg. Which of the following interventions should the nurse delegate to assistive personnel?
- A. Ask the client to describe her pain.
- B. Check the client's pedal pulse on the right leg
- C. Observe the position of the suspended weight
- D. Remind the client to use the incentive spirometer.
Correct Answer: D
Rationale: Correct Answer: D. Remind the client to use the incentive spirometer.
Rationale:
1. Incentive spirometer use is a task that can be safely delegated to assistive personnel.
2. It is a non-invasive procedure and does not require advanced nursing skills.
3. Using the incentive spirometer helps prevent respiratory complications post-surgery.
4. Assistive personnel can remind the client to use it regularly, promoting lung expansion and preventing atelectasis.
Summary of other choices:
A: Asking the client to describe pain requires nursing assessment skills.
B: Checking the client's pedal pulse requires nursing assessment skills.
C: Observing the position of the suspended weight requires nursing judgment to adjust if needed.
Which of the following statements by a client indicates an understanding of the teaching?
- A. I should take antibiotics when I have a virus.
- B. I can visit my nephew who has chickenpox S days after the sores have crusted.
- C. I can clean my cat's litter box during my pregnancy.
- D. I should wish my hands for 10 seconds with hat water after working in the garden.
Correct Answer: B
Rationale: Chickenpox sores crust over before becoming non-contagious.
The nurse should first anticipate-------, followed by-----------
- A. obtain IV access
- B. place the client o a supine position with feet elevated
- C. recheck the diene's oxygen saturation
- D. Call the surgical suite to notify that the client is arriving STAT
- E. prepare to administer TV fluids
- F. check an arterial blood gas
- G. check an ECG
Correct Answer: A,E
Rationale: The correct answer is A, obtain IV access, and E, prepare to administer IV fluids. First, obtaining IV access is essential to establish a route for administering medications and fluids. This step is crucial in a critical situation to ensure quick access for emergency interventions. Next, preparing to administer IV fluids is important to address potential fluid imbalances or hypovolemia in the client. The other choices are incorrect because placing the client in a supine position with feet elevated (B) may be contraindicated in certain conditions, rechecking oxygen saturation (C) may delay urgent interventions, calling the surgical suite (D) is premature without stabilizing the client first, checking an arterial blood gas (F) and ECG (G) are important but not immediate priorities in this scenario.