Nokea
While reviewing the monitor tracing of a client in labor, a nurse notes late decelerations. Which of the following interventions should the nurse perform?
- A. Administer oxygen via nasal cannula
- B. Reposition the client onto her left side
- C. Administer an amnioinfusion
- D. Provide reassurance to the client
Correct Answer: B
Rationale: Repositioning the client onto her left side is the appropriate intervention when late decelerations are noted on the monitor tracing. This action helps increase uteroplacental blood flow by relieving pressure on the vena cava and aorta, improving fetal oxygenation. Administering oxygen via nasal cannula may be indicated for variable decelerations, not late decelerations. Administering an amnioinfusion is not the primary intervention for late decelerations. Providing reassurance to the client is important but addressing the underlying cause of late decelerations takes precedence.
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If a nurse administers an incorrect dose of medication, which fact related to the incident report should the nurse document in the client's medical record?
- A. Time the medication was given
- B. The client's response to the medication
- C. The dose that was administered
- D. Reason for the error
Correct Answer: A
Rationale: The correct answer is to document the time the medication was given. This is essential for understanding the sequence of events surrounding the medication error. While documenting the client's response to the medication (Choice B) is important for assessing any effects, the immediate concern should be to establish a clear timeline by documenting the time of administration. Recording the dose administered (Choice C) is also important, but in the context of understanding the incident, the time factor takes precedence. The reason for the error (Choice D) should be included in the incident report but may not be the first priority when documenting in the client's medical record.
A patient is receiving chemotherapy and has developed stomatitis. Which of the following dietary recommendations should the nurse make?
- A. Eat salty foods to stimulate salivation.
- B. Avoid spicy foods.
- C. Increase intake of high-fiber foods.
- D. Consume cold foods to soothe the mucosa.
Correct Answer: D
Rationale: Correct choice: Consume cold foods to soothe the mucosa. Cold foods can help soothe the mucosa and reduce discomfort for patients with stomatitis caused by chemotherapy.\nIncorrect choices: A) Salty foods may irritate the mucosa further. B) Spicy foods can increase discomfort and irritation. C) High-fiber foods may be rough and abrasive, exacerbating the condition.
A client with osteoporosis needs to increase calcium intake. Which of the following foods should be recommended by the nurse?
- A. Carrots
- B. Broccoli
- C. Chicken
- D. Bananas
Correct Answer: B
Rationale: The correct answer is B: Broccoli. Broccoli is rich in calcium and is a suitable food to recommend to clients with osteoporosis to increase their calcium intake. Carrots, chicken, and bananas are not as high in calcium content compared to broccoli and therefore not the most appropriate choices for increasing calcium intake in clients with osteoporosis.
A client with diabetes mellitus is receiving teaching from a nurse about foot care. Which of the following instructions should the nurse include?
- A. Soak your feet in warm water daily.
- B. Wear cotton socks.
- C. Use a heating pad to warm your feet.
- D. Trim toenails straight across.
Correct Answer: D
Rationale: The correct answer is to trim toenails straight across. This instruction is crucial for clients with diabetes to prevent ingrown toenails, which can lead to infection. Soaking feet in warm water daily can increase the risk of skin breakdown. Cotton socks are recommended, but the priority in foot care for diabetes is proper nail trimming. Using a heating pad can also pose a burn risk for individuals with reduced sensation in their feet.
Which lab value is critical for monitoring warfarin therapy?
- A. Monitor INR
- B. Monitor platelet count
- C. Monitor sodium levels
- D. Monitor calcium levels
Correct Answer: A
Rationale: The correct answer is A: Monitor INR. INR (International Normalized Ratio) is crucial for monitoring warfarin therapy as it helps assess the therapeutic effectiveness and bleeding risks associated with the medication. INR measures the clotting tendency of blood, which is essential in determining the appropriate dosage of warfarin. Monitoring platelet count (B), sodium levels (C), or calcium levels (D) is not primarily used for assessing warfarin therapy. Platelet count is more relevant in assessing bleeding disorders, while sodium and calcium levels are typically monitored for different medical conditions unrelated to warfarin therapy.