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The staff nurse is reviewing how to manage the last 2 hours of the night shift on an antepartal unit and has the following orders and tasks to complete prior to 7 a.m. The nurse should complete the tasks in which order?
- A. Check documentation, final check of each client.
- B. Fetal monitor strip for 1/2 hour q shift.
- C. Magnesium sulfate drawn at 6 a.m.
- D. Accucheck and sliding scale insulin due at 7, 11, 4, and hs.
Correct Answer: D,G,F,A
Rationale: To manage time effectively: Check documentation and final client checks at 6:30 to ensure all records are complete (A); perform the fetal monitor strip from 6:00 to 6:30 to meet the half-hour requirement (F); draw magnesium sulfate at 6:00 to align with the ordered time (G); perform Accucheck and insulin at 7:00 as per the schedule (D).
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A client is taking 600 mg of valproic acid (Depakene) twice daily. The nurse should assess the client for which of the following? Select all that apply.
- A. Tremors.
- B. Hair loss.
- C. Gastrointestinal upset.
- D. Anorexia.
- E. Weight gain.
Correct Answer: A,C,E
Rationale: Valproic acid commonly causes tremors, gastrointestinal upset (e.g., nausea), and weight gain. Hair loss and anorexia are less common side effects.
The nurse is caring for a client who has just undergone a cesarean section. Which of the following interventions is most important in the immediate postoperative period?
- A. Encouraging early ambulation.
- B. Administering oral fluids immediately.
- C. Monitoring for signs of infection.
- D. Applying heat to the incision site.
Correct Answer: A
Rationale: Encouraging early ambulation post-cesarean section prevents complications like deep vein thrombosis and promotes recovery.
The nurse is performing Leopold’s maneuvers on a woman who is in her eighth month of pregnancy. The nurse is palpating the uterus as shown below. Which of the following maneuvers is the nurse performing?
- A. First maneuver.
- B. Second maneuver.
- C. Third maneuver.
- D. Fourth maneuver.
Correct Answer: C
Rationale: The third maneuver is used to identify the presenting part. This maneuver is used to identify the part of the fetus that lies over the inlet to the pelvis. While facing the client, the nurse places the tips of the fi rst three fi ngers on the side of the woman’s abdomen above the symphysis pubis and palpates deeply around the presenting part to identify its contour and size. The first maneuver involves using the tips of the fi ngers of both hands to palpate the uterine fundus. The second maneuver identifi es the back of the fetus, and the fourth maneuver identifies the cephalic prominence
The nurse is caring for a client with a closed head injury. Which finding indicates increasing intracranial pressure?
- A. Widening pulse pressure
- B. Tachycardia
- C. Hyperthermia
- D. Hypotension
Correct Answer: A
Rationale: Widening pulse pressure (e.g., increasing systolic with stable diastolic) is a sign of increasing intracranial pressure, part of Cushing's triad.
You are preparing to administer a PRN medication for pain. After your assessment of the client for pain you open the narcotics cabinet with the special key. Your calculations indicate that the client will be getting 0.8 mLs of the medication and the unit dose vial is 1 mL. You discard the excess of 0.2 mLs into the sink drain and enter the client's room. After you identify the client using two unique identifiers, the client refuses the medication. You then discard the 0.8 mLs into the sink and document the client's refusal on the narcotics count record. What have you failed to do during this process?
- A. You have failed to have another nurse witness the 0.8 mLs and the 0.2 mLs of waste.
- B. You have failed to have another nurse witness the 0.8 mLs of waste.
- C. You have failed to have another nurse witness the 0.2 mLs of waste.
- D. You have failed ask another nurse to verify the calculation of the dosage.
Correct Answer: A
Rationale: Narcotic wastage (both 0.2 mL and 0.8 mL) requires a witness to ensure accountability and prevent diversion, per standard protocol.