Nokea
To prevent a compromise in placental blood flow during the intraoperative period, which of the following actions should the nurse take?
- A. Position the client in reverse Trendelenburg
- B. Place a wedge under one of the client's hips.
- C. Assist the client into the lithotomy position.
- D. Insert a pillow under the clients frees
Correct Answer: B
Rationale: Hip wedges optimize maternal blood flow.
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Which of the following actions by the client indicates an understanding of the teaching?
- A. Stepping with his affected leg first when going up stairs
- B. Moving both crutches with the stronger leg forward first
- C. Supporting his body weight while leaning on the axillary crutch pads
- D. Positioning both hands on the grips with his elbows slightly flexed
Correct Answer: D
Rationale: Proper hand positioning ensures effective crutch use.
A nurse is assessing a client who is in active labor. Which of the following findings should the nurse report to the provider?
- A. Temperature 37.4° C(99,3° F)
- B. Early decelerations in the FHR
- C. FHR baseline 170/min
- D. Contractions lasting 80 seconds
Correct Answer: C
Rationale: The correct answer is C: FHR baseline 170/min. A baseline fetal heart rate (FHR) of 170/min is considered tachycardia and may indicate fetal distress. The nurse should report this finding to the provider for further evaluation and intervention. Early decelerations in fetal heart rate (choice B) are generally considered normal and do not require immediate reporting. A slightly elevated temperature (choice A) may not be concerning during labor. Contractions lasting 80 seconds (choice D) can be normal in active labor.
Which of the following is an appropriate action by the nurse?
- A. Suggest rinsing his mouth with an alcohol-based mouth wash
- B. Provide humidification of the room air.
- C. Offer the client saltine crackers between meals
- D. Instruct the client on the use of esophageal speech
Correct Answer: B
Rationale: The correct answer is B: Provide humidification of the room air. Humidification helps to moisturize the air, making it easier for the client to breathe, especially if they have dry mouth or throat. This can improve comfort and prevent irritation. Choice A is incorrect because alcohol-based mouthwash can further dry out the mouth. Choice C is incorrect as saltine crackers can exacerbate dry mouth. Choice D is incorrect as esophageal speech is not related to addressing dry mouth.
The nurse should identify that which of the following client findings requires follow-up care?
- A. A client who is taking bumetanide and has a potassium level of 3.6 mEq/L
- B. A client who is scheduled for a colonoscopy and is taking sodium phosphate
- C. A client who is taking warfarin and has an INR of 1.8
- D. A client who received a Mantoux test 48 hr ago and has an induration
Correct Answer: C
Rationale: The correct answer is C. A client taking warfarin with an INR of 1.8 requires follow-up care as the INR is subtherapeutic, increasing the risk of clot formation. A therapeutic INR for clients on warfarin is typically between 2-3. Options A, B, and D do not require immediate follow-up care. A potassium level of 3.6 mEq/L is within the normal range. Sodium phosphate for a colonoscopy preparation is appropriate. An induration after a Mantoux test is an expected finding.
After puncturing the skin with the vascular access device and noting a blood return in the flashback chamber, which of the following actions should the nurse perform next?
- A. Flush the catheter with saline
- B. Retract the stylet
- C. Advance the catheter into the vein
- D. Release the tourniquet
Correct Answer: C
Rationale: The correct answer is C: Advance the catheter into the vein. After confirming blood return in the flashback chamber, advancing the catheter ensures proper placement within the vein for medication delivery. Retracting the stylet (B) prematurely can displace the catheter. Flushing with saline (A) before confirming placement is risky. Releasing the tourniquet (D) is done after securing catheter placement.