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A nurse is caring for a client who states he recently purchased lavender oil to use when he gets the flu.
The nurse should recognize which of the following findings as a potential contraindication for using lavender?
- A. The client has a history of asthma
- B. The client takes furosemide twice daily
- C. The client has a history of alcohol use disorder
- D. The client takes vitamin C daily
Correct Answer: A
Rationale: The correct answer is A: The client has a history of asthma. Lavender can trigger asthma symptoms due to its volatile organic compounds. People with asthma may experience worsened symptoms or even asthma attacks when exposed to lavender. Asthma is a contraindication as it can lead to serious health complications.
Explanation for other choices:
B: The client takes furosemide twice daily - Furosemide is a diuretic and does not interact significantly with lavender.
C: The client has a history of alcohol use disorder - Alcohol use disorder does not directly contraindicate the use of lavender.
D: The client takes vitamin C daily - Vitamin C does not interact significantly with lavender.
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A nurse is admitting an older adult client who was transferred from another facility.
Which action should the nurse take to address suspicion of elder abuse?
- A. Privately interview the client about the injuries
- B. Document the injuries in detail, including size, location, and appearance
- C. Report the findings to the appropriate authorities, following facility protocol
- D. Take photographs of the injuries if permitted, as part of the documentation process
- E. Ensure that the client is not left alone with the suspected abuser during the interview or assessment
Correct Answer: C
Rationale: The correct action for the nurse to address suspicion of elder abuse is to report the findings to the appropriate authorities, following facility protocol (Choice C). This is because reporting to the authorities is crucial to protect the elderly individual from further harm and ensure that the necessary interventions are implemented.
- Choice A: Privately interviewing the client may jeopardize the safety of the elderly individual and may not be the most effective immediate action.
- Choice B: Documenting the injuries is important but reporting to authorities takes precedence in cases of suspected elder abuse.
- Choice D: Taking photographs of the injuries may be helpful for documentation but should not delay reporting to authorities.
- Choice E: Ensuring the client is not left alone with the suspected abuser is important but is not as urgent as reporting the abuse to the authorities.
In conclusion, reporting the findings to the appropriate authorities is the most critical and immediate action to address suspicion of elder abuse.
A nurse is caring for a client in active labor.
Admission Assessment
0200:
Gravida 1, Para 0 at 39 weeks gestation. Presents with contractions occurring every 5 to 6 min,
45 to 60 seconds duration. Cervical examination 4 cm dilated, 50% effaced. Admit to labor and
delivery unit.
Nurses' Notes
0200:
Admitted to labor and delivery unit, reports pain as 7 on a scale of 0 to 10 with contractions.
Cervix 4 cm dilated, 50% effaced, with membranes intact.
0230:
Client reports increasing discomfort with contractions. Cervix 5 cm dilated, 60% effaced, with
membranes intact. Contractions occurring every 5 min, 45 to 60 seconds duration.
0300:
Epidural anesthesia initiated, Cervix 7 cm dilated, 70% effaced, with membranes intact.
Contractions occurring every 4 to 5 min. 60 seconds duration,
Vital Signs
0200:
Temperature 36.9° C (98.4° F)
Heart rate 86/min
Respiratory rate 18/min
BP 118/78 mm Hg
0230:
Temperature 37° C (98.6° F)
Heart rate 88/min
Respiratory rate 20/min
BP 120/80 mm Hg
0300:
Temperature 37.1°C?98.8°F?
Heart rate 90/min
Respiratory rate 18/min
BP 122/76 mm Hg
The nurse is assuming care for the client at 0305.
For each nursing action, click to specify if the nursing action is essential or contraindicated for the client.
- A. Assist the client with ambulation
- B. Inform the client to expect drowsiness
- C. Monitor for elevated temperature
- D. Assess for urinary retention
- E. Encourage the client to turn from side to side
Correct Answer: C,D,E
Rationale: Monitoring temperature, assessing urinary retention, and encouraging position changes are essential after epidural administration.
The nurse is continuing to care for the child
Diagnostic Results
1100:
X-ray of right arm: nondisplaced fracture of radius and ulna at the midpoint.
Assessment
1000:
Child is alert and appears developmentally appropriate for their age and well nourished.
Respirations easy and unlabored. Abdomen nondistended. Right forearm and fingers are
edematous. Ecchymotic area noted on outer aspect of the forearm. Radial pulse +2. Fingers
slightly cool to touch. Child can move fingers and reports a mild "tingling" sensation. Child
verbalizes a pain level of 4 on a scale of 0 to 10. Abrasion noted on right knee. No active
bleeding. Multiple areas of bruising noted on lower extremities in various stages of healing
1145:
Edema in right forearm and fingers is mildly increased. Child states that mild tingling in fingers
is unchanged. Able to move all fingers equally. Radial pulse is equal in both extremities, Right
hand fingers are slightly cooler than left hand fingers.
Select the 3 priority actions that the nurse should take.
- A. Review cast care instructions with the child's parents
- B. Administer Ibuprofen 200 mg PO
- C. Place a nonadherent dressing on the right knee abrasion.
- D. Explain the cast application procedure to the child.
- E. Apply ice packs to the fingers and along the right forearm.
- F. Elevate the affected forearm with pillows.
Correct Answer: B,C,F
Rationale: Administering pain relief, protecting the abrasion, and elevating the limb reduce swelling and promote comfort.
A nurse is teaching a client about family planning using the basal body temperature method.
Which of the following instructions should the nurse include in the teaching?
- A. Take your temperature immediately after waking and before getting out of bed.
- B. Measure your temperature in the afternoon for the most accurate reading.
- C. A rise in body temperature of at least 2°F indicates ovulation has occurred.
- D. Use a standard digital thermometer for the most precise results.
Correct Answer: A
Rationale: The correct answer is A: Take your temperature immediately after waking and before getting out of bed. This instruction is part of basal body temperature monitoring for ovulation tracking. Body temperature is lowest upon waking and increases after ovulation, so taking the temperature before getting out of bed provides the most accurate baseline measurement. Choice B is incorrect because afternoon temperatures can fluctuate due to various factors. Choice C is incorrect as a rise of at least 0.4°F, not 2°F, indicates ovulation. Choice D is incorrect because a basal body temperature thermometer is more appropriate for this purpose than a standard digital thermometer.
A nurse is caring for a client who is in active labor.
The nurse should notify the provider for which of the following findings?
- A. Baseline fetal heart rate 115/min
- B. Three uterine contractions within 10 minutes
- C. Prolonged decelerations
- D. Moderate variability in the fetal heart rate
Correct Answer: C
Rationale: The correct answer is C: Prolonged decelerations. This finding indicates potential fetal distress, requiring immediate provider notification to assess and intervene. Baseline fetal heart rate (A) within normal range is reassuring. Three uterine contractions (B) could be normal. Moderate variability (D) is a positive sign of fetal well-being. The focus should be on abnormal findings like prolonged decelerations (C) that may indicate compromised fetal oxygenation.