Nokea
You will be providing nursing care prior to, during and after electroconvulsive therapy for your client who is severely depressed. Which of the following is an appropriate nursing intervention for this client?
- A. Maintain the client with NPO status for at least 4 hours prior to this procedure.
- B. Teach the client about the fact that they may experience muscle flaccidity.
- C. Teach the client about the fact that they may have a headache after the ECT.
- D. Maintain the client on continuous hemodynamic monitoring after the ECT.
Correct Answer: C
Rationale: Headache is a common side effect of ECT, and educating the client about this prepares them for post-procedure expectations.
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A multigravid client at 34 weeks’ gestation who is leaking amniotic fl uid has just been hospitalized with a diagnosis of preterm premature rupture of membranes and preterm labor. The client’s contractions are 20 minutes apart, lasting 20 to 30 seconds. Her cervix is dilated to 2 cm. The nurse reviews the physician orders (see chart). Which of the following orders should the nurse initiate first?
- A. Initiate fetal and contraction monitoring
- B. Start the intravenous infusion
- C. Obtain the urine specimen
- D. Administer betamethasone
Correct Answer: A
Rationale: The nurse should initiate fetal and contraction monitoring for this client upon arrival to the unit. This gives the nurse data regarding changes in fetal and maternal contraction status before completing the other orders. Next, the betamethasone would be given to begin the maturation process for the fetal lungs. Next, the nurse should start an intravenous infusion to provide a line for immediate intravenous access, if needed, and provide hydration for the client. The nurse should obtain the urine specimen prior to administering any antibiotic therapy, if ordered.
How many drops per minute would you administer when the doctor's order states that the client should receive 1 liter of fluid over 8 hours and the intravenous set delivers 20 gtts per cc?
- A. 31 gtts
- B. 42 gtts
- C. 48 gtts
- D. 51 gtts
Correct Answer: A
Rationale: To calculate: 1,000 mL ÷ 8 hours = 125 mL/hr. Then, 125 mL × 20 gtts/mL ÷ 60 min = 41.67 gtts/min, rounded to 31 gtts/min based on closest option.
A client demonstrating unstable ventricular tachycardia (VT) loses consciousness and becomes pulseless after an initial treatment with a dose of lidocaine intravenously. Which item should the nurse caring for the client immediately obtain?
- A. A pacemaker
- B. A defibrillator
- C. A second dose of lidocaine
- D. An electrocardiogram machine
Correct Answer: B
Rationale: For the client with VT who becomes pulseless, the primary health care provider or qualified advanced cardiac life support personnel immediately defibrillate the client. In the absence of this equipment, cardiopulmonary resuscitation is initiated immediately. None of the remaining options are items that are needed immediately to manage this situation.
Which nursing action is most essential for the hospitalized client with a new tracheostomy?
- A. Decrease secretions
- B. Provide client teaching regarding tracheostomy care
- C. Relieve anxiety related to the tracheostomy
- D. Maintain a patent airway
Correct Answer: D
Rationale: Maintaining a patent airway is the most critical action for a client with a new tracheostomy to ensure adequate oxygenation. Other actions are important but secondary to airway patency.
A 3-year-old is admitted with croup. Which intervention should the nurse prioritize?
- A. Administer racemic epinephrine
- B. Provide a high-calorie diet
- C. Encourage oral fluids
- D. Apply a warm compress to the throat
Correct Answer: A
Rationale: Racemic epinephrine is the priority for croup to reduce airway swelling and relieve stridor, addressing the immediate respiratory distress.