Nokea
Which of the following actions should the nurse include when teaching about interacting with a client who is aggravated, pacing, and speaking loudly?
- A. Initiate seclusion protocol.
- B. Tell the client, 'You seem to be very upset.'
- C. Stand directly in front of the client and maintain eye contact.
- D. Speak in a firm and authoritative tone to gain control of the situation
Correct Answer: B
Rationale: The correct answer is B - Tell the client, 'You seem to be very upset.' This response shows empathy and acknowledgment of the client's emotions, which can help de-escalate the situation. It validates the client's feelings and opens the door for effective communication. Initiating seclusion protocol (A) may escalate the situation and should only be used as a last resort for safety. Standing directly in front of the client and maintaining eye contact (C) can be perceived as confrontational and may increase agitation. Speaking in a firm and authoritative tone (D) may further escalate the client's emotions. It is important to approach the situation with empathy and understanding to establish a therapeutic relationship.
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Which pain management technique should the nurse suggest?
- A. Provide information about the use of hydrotherapy during labor
- B. Encourage the use of breathing techniques to manage pain.
- C. Suggest the use of massage or counterpressure to relieve discomfort.
- D. Recommend positioning changes, such as walking or rocking, to ease pain.
- E. Support the use of relaxation techniques, such as visualization, to reduce stress.
Correct Answer: B
Rationale: The correct answer is B: Encourage the use of breathing techniques to manage pain. Breathing techniques help in pain management by promoting relaxation, reducing anxiety, and increasing oxygen flow. This can help the laboring individual cope better with contractions. Other choices are less effective for pain management in labor. A: Hydrotherapy can be beneficial, but breathing techniques are more universally applicable. C: Massage and counterpressure can help, but may not be as effective as breathing techniques during labor. D: Positioning changes are helpful, but breathing techniques are more directly focused on pain management. E: Relaxation techniques like visualization are useful, but breathing techniques are more specifically targeted at managing pain.
Which of the following actions should the nurse include in the plan of care?
- A. Observe for bruising of the skin
- B. Provide a diet low in protein
- C. Monitor v/s every hour for the first 4 hr.
- D. Administer medications intramuscularly
Correct Answer: A
Rationale: The correct answer is A: Observe for bruising of the skin. This is important in assessing for potential complications such as bleeding disorders, which may indicate a need for further intervention. Providing a diet low in protein (B) is not relevant to the scenario unless specified. Monitoring vital signs every hour for the first 4 hours (C) may not be necessary unless there are specific concerns. Administering medications intramuscularly (D) is not indicated without further context.
Which of the following interventions should the nurse include in the plan of care? Select all that apply.
- A. Increase oxygen flow rate to 4 L/min.
- B. Assess the client's breath sounds
- C. Perform chest percussion and vibration.
- D. Place the client in a supine position.
- E. Restrict the client's fluid intake.
- F. Instruct the client to perform diaphragmatic breathing
Correct Answer: A,B,F
Rationale: The correct interventions are A, B, and F.
A: Increasing oxygen flow rate to 4 L/min ensures adequate oxygenation for the client.
B: Assessing breath sounds helps monitor respiratory status and detect any abnormalities.
F: Instructing the client to perform diaphragmatic breathing promotes effective use of respiratory muscles.
Incorrect choices:
C: Chest percussion and vibration are not typically indicated for all clients and may not be appropriate in this case.
D: Placing the client in a supine position can worsen respiratory function, especially in certain conditions.
E: Restricting fluid intake may not be necessary unless specifically ordered by a healthcare provider and could potentially lead to dehydration.
Select the findings that indicate the interventions have been effective.
- A. Client rates pain with contractions as a 3 on a scale of 0 to 10
- B. Contractions occurring every 2.5 to 3 minutes, lasting 60 to 70 seconds
- C. Accelerations present, no decelerations noted
- D. Heart rate 88/min
- E. Blood pressure 122/80 mm Hg
- F. Temperature 38° C(100.4° F)
Correct Answer: A,C
Rationale: Effective pain relief (client rates pain as 3) and normal FHR patterns indicate successful interventions.
Which of the following actions should the nurse plan to take?
- A. Keep calcium gluconate at the client's bedside
- B. Monitor blood pressure every 2 hr.
- C. Protect IV bag from exposure to light.
- D. Attach an inline filter to the IV tubing.
Correct Answer: C
Rationale: The correct answer is C: Protect IV bag from exposure to light. This is important because certain medications in IV bags can degrade when exposed to light, leading to reduced efficacy or potential harm to the patient. Keeping the IV bag protected helps maintain the integrity of the medication.
Choice A is incorrect because calcium gluconate should be stored properly but doesn't necessarily need to be kept at the bedside at all times.
Choice B is incorrect as monitoring blood pressure every 2 hours may not be necessary for all patients and is not specific to the scenario given.
Choice D is incorrect as attaching an inline filter to the IV tubing may be necessary in certain situations but is not the most relevant action based on the information provided.