Nokea
Which of the following statements by the client indicates an understanding of the teaching?
- A. I should not use my affected hand for 4 to 6 weeks.
- B. I will need to keep my hand elevated above my heart for several days.
- C. I should expect numbness and tingling in my hand.
- D. I can apply heat for the first 24 hours to minimize the pain in my hand.
Correct Answer: B
Rationale: Elevation reduces swelling postoperatively.
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While performing a routine assessment, a nurse notices fraying on the electrical cord of a client's continuous passive motion(CPM) device. Which of the following actions should the nurse take first?
- A. Initiate a requisition for a replacement CPM device.
- B. Report the defect to the equipment maintenance staff.
- C. Remove the device from the room.
- D. Ensure the device inspection sticker is current.
Correct Answer: C
Rationale: The correct answer is C: Remove the device from the room. The fraying electrical cord poses a serious safety hazard, risking electrical shock or fire. The first step is to remove the device to prevent harm to the client or others. Initiating a requisition (A) or reporting to maintenance staff (B) can follow, but immediate removal is crucial. Ensuring the inspection sticker is current (D) is not the priority when there is a safety issue.
For each potential nursing action, click to specify if the action is indicated or not indicated for the client.
- A. Document the blood product transfusion in the client's medical record.
- B. Stay with the client for the first 15 min of the transfusion
- C. Titrate the rate of infusion to maintain the client's blood pressure at least 91/60 mm. Hg
- D. Obtain the first unit of packed RBCS from the blood bank.
- E. Start an IV bolus of lactated Ringers solution.
Correct Answer: A,B,D
Rationale: [A: 1, B: 1, C: 0, D: 1, E: 0, F: , G: ]
- A: Documenting blood product transfusion is crucial for legal and tracking purposes.
- B: Staying with the client ensures immediate response to any adverse reactions.
- C: Titration of infusion rate for BP is not within nursing scope without physician order.
- D: Obtaining packed RBCs precedes transfusion to verify compatibility.
- E: Starting IV bolus of LR is not indicated as it is unrelated to the transfusion process.
Select the 5 findings that require immediate follow-up
- A. Stool results
- B. Hemoglobin and Hematocrit
- C. Respiratory rate
- D. Heart rate
- E. Current medications
- F. Temperature
- G. WIC count
Correct Answer: A,B,D,E,H
Rationale: The correct choices for immediate follow-up are A, B, D, E, and H. Stool results (A) are crucial for detecting gastrointestinal issues. Hemoglobin and hematocrit (B) levels indicate blood health. Heart rate (D) reflects cardiovascular function. Current medications (E) help assess potential drug interactions. WIC count (H) is essential for monitoring infection. Respiratory rate (C) and temperature (F) are important but not as urgent.
The client is at risk for developing ------- and--------
- A. Hypoglycemia
- B. bronchopulmonary dysplasia
- C. transient tachypnea of the newborn
- D. Tachycardia
Correct Answer: A, C
Rationale: The correct answer is A and C. Hypoglycemia and transient tachypnea of the newborn are common risks for newborns. Hypoglycemia can occur due to immature liver function, while transient tachypnea results from retained lung fluid. The other choices are incorrect because bronchopulmonary dysplasia is a chronic lung condition seen in premature infants, and tachycardia is a symptom of various conditions but not typically a primary risk for newborns.
Which of the following actions should the nurse take?
- A. Place the client in a side-lying position prior to assessing the fetal heart rate.
- B. Measure the fundal height to determine the placement of the ultrasound stethoscope.
- C. Position the ultrasound stethoscope above the symphysis pubis to assess the fetal heart rate.
- D. Perform Leopold maneuvers prior to auscultating the fetal heart rate.
Correct Answer: C
Rationale: The correct answer is C: Position the ultrasound stethoscope above the symphysis pubis to assess the fetal heart rate. This is the correct action because placing the ultrasound stethoscope above the symphysis pubis allows for optimal detection of the fetal heart rate. This location is where the fetal heart sounds are best heard due to the proximity to the fetal heart. Placing the stethoscope in this location ensures accurate assessment of the fetal heart rate.
Choice A is incorrect because placing the client in a side-lying position is not necessary for assessing the fetal heart rate with an ultrasound stethoscope. Choice B is incorrect because measuring fundal height is not relevant to assessing the fetal heart rate. Choice D is incorrect because Leopold maneuvers are used to determine fetal position and presentation, not to assess the fetal heart rate.