Nokea
When caring for a laboring client whose contractions are occurring every 2-3 minutes, the nurse should document that the pump is infusing how many ml/hour? (Enter numeric value only. If rounding is required, round to the nearest whole number. Click on each chart tab for additional information. Please be sure to scroll to the bottom right corner of each tab to view all information contained in the client's medical record.)
- A. 5
- B. 10
- C. 15
- D. 20
Correct Answer: A
Rationale: The correct infusion rate can be calculated based on the information provided in the chart. With contractions occurring every 2-3 minutes, the recommended infusion rate is 5 ml/hr. This rate ensures proper hydration and medication delivery to support the client during labor. Choices B, C, and D are incorrect as they do not align with the calculated rate based on the contractions frequency and the client's needs.
You may also like to solve these questions
A continuous infusion of nitroglycerin is prescribed for an adult male admitted with an acute myocardial infarction. The client is experiencing active chest pain that he describes as 8 out of 10. Which intervention is most important for the nurse to implement?
- A. Administer the infusion via an infusion pump
- B. Obtain the current serum potassium level
- C. Continuously monitor blood pressure
- D. Teach guided imagery to decrease pain
Correct Answer: C
Rationale: Continuously monitoring blood pressure is crucial in this case because nitroglycerin can cause hypotension as a side effect. Monitoring blood pressure allows the nurse to assess the client's response to the medication and detect any signs of hypotension promptly. This intervention is essential to ensure the effectiveness of nitroglycerin therapy and prevent potential complications. Administering the infusion via an infusion pump is important for accurate dosing but not the most critical at this moment. Obtaining the current serum potassium level is important but not the most immediate concern when the client is experiencing active chest pain. Teaching guided imagery may be beneficial for pain management, but in this scenario, monitoring blood pressure takes precedence due to the potential side effects of nitroglycerin.
Which medication should the nurse anticipate administering to a client who is diagnosed with myxedema coma?
- A. Intravenous administration of thyroid hormones
- B. Oral administration of hypnotic agents
- C. Intravenous bolus of hydrocortisone
- D. Subcutaneous administration of vitamin K
Correct Answer: A
Rationale: The correct answer is A: Intravenous administration of thyroid hormones. Myxedema coma is a severe form of hypothyroidism that necessitates immediate replacement of thyroid hormones. Administering thyroid hormones intravenously ensures rapid absorption and effectiveness in managing the condition. Choice B, oral administration of hypnotic agents, is incorrect as it does not address the primary issue of thyroid hormone deficiency in myxedema coma. Choice C, intravenous bolus of hydrocortisone, is not the appropriate treatment for myxedema coma as adrenal insufficiency is not the primary concern in this condition. Choice D, subcutaneous administration of vitamin K, is unrelated to the management of myxedema coma and does not address the underlying thyroid hormone deficiency that characterizes this condition.
The parents of a child who had surgical repair of a myelomeningocele are being taught how to change an occlusive dressing on the child's back. Which statement by the parents indicates that they understand this procedure?
- A. When changing the dressing, the tape should be removed slowly to prevent trauma to the skin
- B. To prevent infection, the dressing should be kept dry to avoid excess moisture
- C. The skin incision should be kept moist to promote healing and prevent dryness
- D. The incision should be protected from fecal contamination by an intact dressing
Correct Answer: D
Rationale: The correct answer is D because protecting the incision from fecal contamination is essential to prevent infection and promote healing in a child with a myelomeningocele. This is crucial as fecal matter can introduce harmful bacteria to the wound. Choice A is incorrect as removing the tape slowly to prevent trauma to the skin is a general guideline but not specific to preventing infection. Choice B is incorrect because keeping the dressing dry can lead to complications as the wound needs a moist environment to heal properly. Choice C is incorrect as keeping the skin incision moist may promote infection and delay healing, making it an incorrect statement for postoperative care.
A client with acute renal failure (ARF) is admitted for uncontrolled type 1 diabetes mellitus and hyperkalemia. The nurse administers an IV dose of regular insulin per sliding scale. Which intervention is the most important for the nurse to include in this client's plan of care?
- A. Monitor the client's cardiac activity via telemetry.
- B. Maintain venous access with an infusion of normal saline.
- C. Assess glucose levels via finger stick every 4 to 6 hours.
- D. Evaluate hourly urine output for the return of normal renal function.
Correct Answer: A
Rationale: Monitoring cardiac activity is crucial in this scenario because hyperkalemia can lead to serious cardiac dysrhythmias, which can be life-threatening. Regular monitoring of the client's cardiac activity via telemetry allows for early detection of any potential cardiac complications. Maintaining venous access with a normal saline infusion is important for hydration but does not address the immediate risk of cardiac dysrhythmias posed by hyperkalemia. Assessing glucose levels is essential in diabetes management but is not the priority when dealing with hyperkalemia-induced cardiac risks. Evaluating hourly urine output for the return of normal renal function is important in ARF but is not as urgent as monitoring the client's cardiac activity in the context of hyperkalemia.
To differentiate adventitious lung sounds associated with heart failure from those associated with bacterial pneumonia, what information should the nurse review?
- A. Sputum culture findings
- B. Oxygen saturation level
- C. Amount of coughing
- D. Respiratory rate
Correct Answer: A
Rationale: The correct answer is A: Sputum culture findings. Reviewing sputum culture findings can provide valuable information to differentiate between bacterial pneumonia and heart failure, as the type of bacteria present in the sputum can help identify the specific infection. Oxygen saturation level (Choice B) is important for assessing oxygenation status but does not directly help in distinguishing between the two conditions based on lung sounds. The amount of coughing (Choice C) and respiratory rate (Choice D) may offer some clinical insights but are not as specific or diagnostic as sputum culture findings when differentiating between heart failure and bacterial pneumonia.