Nokea
A nurse is planning teaching for a client who has a newly implanted implantable cardioverter/defibrillator.
Which of the following information should the nurse include?
- A. Return in two weeks for a follow up MRI - MRI should be avoided
- B. Expect to have a rapid pulse rate for the first few weeks?
- C. Resume tub baths and swimming after 24hr
- D. Wear loose fitting clothing
Correct Answer: D
Rationale: The correct answer, D, "Wear loose fitting clothing," is important post-surgery to prevent constriction on the surgical site and promote healing. Tight clothing can lead to increased pain and delayed recovery. Choice A is incorrect as MRI should be avoided post-surgery due to potential interference with healing. Choice B is incorrect as a rapid pulse rate is not a typical expectation post-surgery. Choice C is incorrect as tub baths and swimming should be avoided to prevent infection.
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A nurse is caring for a client who is postoperative following a liver biopsy.
In which of the following positions should the nurse place the client immediately following the procedure?
- A. Trendelenburg
- B. Prone
- C. Right lateral
- D. High-fowlers
Correct Answer: C
Rationale: The correct answer is C: Right lateral. Placing the client in the right lateral position immediately following a procedure helps prevent aspiration of secretions or blood, as gravity assists in drainage from the airway. Trendelenburg position (A) is used to increase venous return but is not appropriate post-procedure. Prone position (B) is lying face down and may obstruct airway patency. High-fowlers position (D) is sitting upright at a 90-degree angle, which is not ideal for immediate post-procedure care.
A nurse is caring for a client who has pneumonia and tells the nurse, “I feel like an elephant is sitting on my chest.†The client is weak and unable to walk.
After the nurse indicates chest pain protocol, which of the following is the priority diagnostic test?
- A. PT and INR
- B. 12 lead ECG
- C. Chest X-ray
- D. D-dimer test
Correct Answer: C
Rationale: The correct answer is C: Chest X-ray. When a patient presents with chest pain, a chest X-ray is crucial to evaluate for any acute cardiopulmonary conditions like pneumonia, pneumothorax, or aortic dissection. It helps identify any immediate life-threatening issues that require prompt intervention. PT and INR (A) are coagulation tests not typically indicated for acute chest pain. A 12-lead ECG (B) is important but usually done after the chest X-ray to assess for cardiac abnormalities. D-dimer test (D) is used to rule out pulmonary embolism, but it is not the priority test in the initial evaluation of chest pain.
A nurse is teaching a newly licensed nurse about caring for clients in the emergency department.
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.
The nurse is continuing to care for the child
Provider Prescriptions
1030:
Obtain x-rays of right arm, wrist, and elbow.
1145:
Ibuprofen 200 mg PO PRN pain rating of 5 on a scale of 0 to 10
Consult orthopedic department for cast application.
1400:
Discharge to home.
Follow-up in office in 2 weeks.
Review synthetic cast care instructions with child and family.
After reviewing the discharge instructions with the family, which of the following statements by a parent indicate an understanding of the teaching? Click to specify if the statement reflects an understanding or indicates a need for reinforcement.
- A. We should notify the provider if the cast becomes loose over time.
- B. It is important that our child avoids placing anything inside the cast.
- C. We should prop the casted arm on pillows for the next 24 hours.
- D. We should expect the swelling and tingling to worsen before it gets better.
- E. We need to be very careful about how we handle the cast for the first 2 days while it dries.
Correct Answer: A,B,C,E
Rationale: Statements A, B, C, and E reflect correct understanding. Expecting worsening symptoms (D) requires clarification as it may indicate complications.
The nurse is continuing to care for the client.
Provider Prescriptions Day 1,
1030
Admit to obstetrical unit.
Serum magnesium level per facility policy 24 hr urine
for total protein and creatinine Insert indwelling
urinary catheter Continuous external fetal monitoring
Administer loading dose of magnesium sulfate 4 g via Intermittent IV bolus over 20 min
followed by a maintenance dose of 2 g/hr
Lactated Ringer's 50 ml/tr via continuous iV infusion Betamethasone
12 mg IM X2 doses given 24 hr apart
Labetalol 20 mg IV bolus now, then 100 mg PO twice dally starting at 2000 Vital signs every 30
min
Acetaminophen 650 mg PO every 6 hr PRN pain Hourly intake and
output
The provider has admitted the client to the inpatient obstetrics unit and written prescriptions based on the client's condition. The action the nurse should take first is------followed by ----------
- A. evaluating the fetal heart rate tracing
- B. monitoring urine output
- C. Checking the client's blood pressure
- D. administering labetalol
- E. Starting the continuous IV infusion
- F. inserting an indwelling urinary catheter
Correct Answer: C,D
Rationale: The correct first action is to check the client's blood pressure (Choice C) as it is essential to assess the client's immediate physiological status. High blood pressure in obstetric patients can lead to severe complications. Administering labetalol (Choice D) is the next step if the blood pressure is elevated, as it is a commonly used medication to manage hypertension in pregnancy. Choices A, B, E, and F are important interventions but should be prioritized after addressing the client's blood pressure as they are not directly related to the immediate risk of hypertensive crisis.