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A nurse is providing preoperative teaching to a client about the administration of morphine via a PCA pump.
Which of the following statements by the client indicates an understanding of the teaching?
- A. I will receive a limited amount of pain medication when I press the button.
- B. I should have my family press the button for me when I am asleep.
- C. I can receive as much pain medication as I need by pressing the button.
- D. I should wait until my pain is severe before using the PCA pump.
Correct Answer: A
Rationale: The correct answer is A because it shows the client understands the concept of patient-controlled analgesia (PCA) pump, where they will receive a limited amount of pain medication when they press the button. This indicates the client knows they have control over their pain relief.
Choice B is incorrect as having someone else press the button goes against the purpose of PCA, which is for the patient to self-administer medication. Choice C is incorrect because unlimited medication can lead to overdose. Choice D is incorrect as waiting for severe pain can lead to ineffective pain management.
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A nurse is caring for a client who has placenta previa.
Which finding should the nurse expect?
- A. Spotting
- B. Painless, bright red vaginal bleeding
- C. Soft, relaxed, and non-tender uterus
- D. Fundal height greater than expected for gestational age
- E. Fetal heart rate within normal limits unless significant blood loss occurs
Correct Answer: B
Rationale: The correct answer is B: Painless, bright red vaginal bleeding. This finding is indicative of placenta previa, a condition where the placenta partially or completely covers the cervix. The bright red color indicates fresh bleeding. Spotting (choice A) is more commonly associated with implantation bleeding in early pregnancy. A soft, relaxed, and non-tender uterus (choice C) is not specific to any particular condition. A fundal height greater than expected for gestational age (choice D) could indicate fetal macrosomia or polyhydramnios, but it is not related to the scenario described. While fetal heart rate within normal limits (choice E) is important, it is not the most relevant finding in this case.
A nurse is teaching about preventative measures to a female client who has chronic urinary tract infections.
Which of the following interventions should the nurse include in the teaching?
- A. Drink 2 liters of warm water per day.
- B. Wipe from back to front after urination.
- C. Urinate immediately after sexual intercourse.
- D. Limit fluid intake to prevent frequent urination.
Correct Answer: C
Rationale: The correct answer is C: Urinate immediately after sexual intercourse. This intervention helps prevent urinary tract infections by flushing out bacteria that may have entered the urethra during intercourse. It is important to teach this to promote urinary tract health.
A: Drinking 2 liters of warm water per day is generally good for hydration but not directly related to preventing UTIs.
B: Wiping from back to front can actually introduce bacteria from the rectal area to the urethra, increasing the risk of UTIs.
D: Limiting fluid intake to prevent frequent urination is not recommended as it can lead to dehydration and concentration of urine, potentially worsening UTIs.
A nurse is caring for a client who is in active labor.
The nurse should notify the provider for which of the following findings?
- A. Baseline fetal heart rate 115/min
- B. Three uterine contractions within 10 minutes
- C. Prolonged decelerations
- D. Moderate variability in the fetal heart rate
Correct Answer: C
Rationale: The correct answer is C: Prolonged decelerations. This finding indicates potential fetal distress, requiring immediate provider notification to assess and intervene. Baseline fetal heart rate (A) within normal range is reassuring. Three uterine contractions (B) could be normal. Moderate variability (D) is a positive sign of fetal well-being. The focus should be on abnormal findings like prolonged decelerations (C) that may indicate compromised fetal oxygenation.
A nurse is assessing a client who has type one diabetes myelitis and was administered insulin lispro 1 hour ago.
Which of the following manifestations indicates that the client might be experiencing hypoglycemia?
- A. Confusion
- B. Increased thirst
- C. Frequent urination
- D. Flushed skin
Correct Answer: A
Rationale: The correct answer is A: Confusion. Hypoglycemia is a condition characterized by low blood sugar levels, leading to symptoms like confusion due to the brain not receiving enough glucose for energy. Increased thirst and frequent urination are more indicative of hyperglycemia (high blood sugar levels). Flushed skin is not a common manifestation of hypoglycemia.
A nurse in an emergency department is assessing a client who reports ingesting thirty diazepam tablets a respiratory rate of 10/min.
After securing the client's airway and initiating an IV, which of the following actions should the nurse do next.
- A. Administer flumazenil to the client.
- B. Initiate gastric lavage with activated charcoal.
- C. Place the client in the Trendelenburg position.
- D. Obtain a stat CT scan of the brain.
Correct Answer: A
Rationale: The correct answer is A: Administer flumazenil to the client. Flumazenil is a specific benzodiazepine receptor antagonist used to reverse the effects of benzodiazepine overdose, which includes respiratory depression. Administering flumazenil would help reverse the sedative effects of benzodiazepines and improve the client's respiratory status. Initiating gastric lavage with activated charcoal (B) is not the immediate priority after securing the airway and IV. Placing the client in the Trendelenburg position (C) is not recommended due to potential complications. Obtaining a stat CT scan of the brain (D) is not necessary at this point and does not address the immediate concerns of airway and sedation reversal.