A client with a diagnosis of preeclampsia suddenly begins to exhibit seizure activity. The first action on the part of the nurse is:
Calling the
... [Show More] physician
Inserting an oral airway
Turning the client on her side
Noting the time of the seizure
C
If seizure activity occurs, the nurse remains with the client and presses the emergency bell for assistance. The client is turned on her side because a side-lying position permits greater circulation through the placenta and helps prevent aspiration. The nurse then notes the time and sequence of the seizure. The physician is notified that a seizure has occurred, because this is an obstetric emergency associated with cerebral hemorrhage, abruptio placentae, severe fetal hypoxia, and death. No object should be placed in the client's mouth during a seizure. An airway may be inserted after the seizure, and the client's mouth and nose are suctioned to prevent aspiration. Oxygen may be administered by way of face mask during the seizure to increase oxygenation of the placenta and all maternal organs.
A nurse reviewing the medical history of an infant experiencing gastroesophageal reflux (GER) would expect to note documentation of:
Refusal to suck
Frequent diarrhea
Recurrent otitis media
Inability to pass stools
C
GER is regurgitation of gastric contents back into the esophagus. The three types of GER are physiologic, functional, and pathologic. Vomiting or spitting up after a meal, hiccupping, and recurrent otitis media resulting from pooling of secretions in the nasopharynx during sleep are characteristics of all types of GER. Refusal to suck, diarrhea, and inability to pass stools are not associated with GER.
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A nurse is caring for a client who has just undergone cardioversion. Which of the following interventions is the nurse's priority after this procedure?
Administering oxygen
Monitoring the blood pressure
Administering antidysrhythmic medications
Monitoring the client's level of consciousness
A
Nursing responsibilities after cardioversion include maintenance of a patent airway, oxygen administration, assessment of vital signs and level of consciousness, and detection of dysrhythmias. The priority nursing intervention here is administering oxygen.
A nurse is assigned to conduct an admission assessment of a client who was treated in the emergency department after attempting suicide by cutting her wrists with a razor blade. When the client arrives at the nursing unit, the nurse should first:
Ask the client to sign a no-harm contract
Ask the client to report any suicidal thoughts immediately
Place the client under suicide precautions with 15-minute checks
Check the dressings that were placed over the client's wrists in the emergency department
D
The nurse would first assess the physical status of the client. Therefore, the first nursing intervention is to check the dressings that have been placed over the client's wrists. The nurse would also immediately implement one-to-one suicide precautions (not 15-minute checks) for the client who has attempted suicide. The client would be asked to sign a no-harm contract, but this would not be the first action. Asking the client to report any suicidal thoughts immediately is a component of a no-harm contract.
A nurse is evaluating outcomes for a client with Guillain-Barré syndrome. Which of the following outcomes does the nurse recognize as optimal respiratory outcomes for the client? Select all that apply.
Normal deep tendon reflexes
Improved skeletal muscle tone
Absence of paresthesias in the lower extremities
Clear sounds in the lower lung fields bilaterally
pO2 of 85 mm Hg and Pco2 of 40 mm Hg
D E
Satisfactory respiratory outcomes include clear breath sounds on auscultation, clear mentation, spontaneous breathing, normal vital capacity, and normal arterial blood gases. The ABG results listed here — a Po2 of 85% and a Pco2 of 40 mm Hg — are normal. The presence of normal deep tendon reflexes, improved skeletal muscle tone, and absence of paresthesias in the lower extremities reflect improvement in the symptoms associated with Guillain-Barré but are not specific to a respiratory outcome.
A nurse provides instruction to a client with chronic obstructive pulmonary disease (COPD) about home oxygen therapy. Which statement by the client indicates a need for further instruction? Select all that apply.
"I should limit activity as much as I possibly can."
"If I have trouble breathing, I need to call the doctor."
"I need to drink lots of fluids to keep my mucus thin."
"I can apply Vaseline to my nose if the oxygen dries it out."
"I should wear a scarf over my nose and mouth in cold weather."
"If I get a flu shot, I don't have to worry about being around people with colds."
A D F
Clients with COPD should be encouraged to keep up their daily activities as much as possible to help prevent muscle wasting and maintain activity tolerance. An occupational therapy consult may be useful in helping the client learn how to perform activities in ways that conserve energy. Oxygen is drying to the membranes of the nose, but the client should apply a water-soluble lubricant (K-Y Jelly) to the inside of the nose to reduce dryness and cracking rather than petroleum jelly (Vaseline), which could be inhaled. Every client with COPD should be encouraged to get a yearly flu vaccination, but because of the increased risk of infection, the client must still avoid crowds and people with infections. The remaining options are appropriate home care measures.
A man calls the emergency department and tells the nurse that he sustained a bee sting on his leg while working in his yard. The client states that he is not allergic to bees and wants to know how to treat the sting. The nurse tells the client to first:
Place a cool compress on the sting site
Apply an antipruritic lotion to the sting site
Apply a topical corticosteroid to the sting site
Take an oral antihistamine such as diphenhydramine (Benadryl)
A
Treatment for a bee sting depends on the severity of the reaction. Mild reactions are treated with elevation, cool compresses, antipruritic lotions, and oral antihistamines. Rings, watches, and restrictive clothing are removed. In this situation, there is no information to indicate that the client is experiencing a severe reaction, so the nurse would first tell the client to apply a cool compress to the sting site. More severe reactions are treated with intravenous antihistamines such as diphenhydramine, subcutaneous epinephrine, and corticosteroids.
A nurse provides dietary instructions to the mother of a child with iron-deficiency anemia. The nurse should tell the mother that the food highest in iron is:
Milk
Cheese
Orange juice
Cream of Wheat
D
Foods high in iron include liver, dried beans, Cream of Wheat, iron-fortified cereal, apricots and prunes (and other dried fruits), egg yolks, and dark-green leafy vegetables. Milk and cheese are high in calcium. Orange juice is high in vitamin C.
A nurse provides information to the mother of a child with diarrhea about signs and symptoms that indicate the need to call the physician. Which statement by the mother indicates the need for further instruction?
"I'll call the doctor if she gets dizzy and acts sick."
"I'll call the doctor if she has severe stomach cramps."
"I'll call the doctor if her temperature is 102°F (38.9°C) or higher."
"I'll call the physician if she goes longer than 6 hours without urinating."
C
The mother should call the physician if a fever higher than 100° F, especially one that persists for more than 72 hours, develops. The mother should not wait until the temperature reaches 102° F (38.9°C) . The remaining statements are all accurate because the findings indicate possible dehydration and hypovolemia. Additionally, severe abdominal cramps could indicate the presence of an acute problem.
A client's arterial blood gases (ABGs) are analyzed: pH 7.49, Paco2 31 mm Hg, Pao2 97 mm Hg, HCO3- 22 mEq/L (22 mmol/L). Which of the following acid-base disturbances does the nurse identify from these results?
Metabolic acidosis
Metabolic alkalosis
Respiratory acidosis
Respiratory alkalosis
D
Acidosis is defined as a pH of less than 7.35, whereas alkalosis is defined as a pH greater than 7.45. Respiratory acidosis is present when the Paco2 is greater than 45 mm Hg; respiratory alkalosis is present when the Paco2 is less than 35 mm Hg. Metabolic acidosis is present when the HCO3- is less than 22 mEq/L (22 mmol/L); metabolic alkalosis is present when the HCO3- is greater than 26 mEq/L (26 mmol/L) . This client's ABG results are consistent with respiratory alkalosis.
A nurse is assessing a client who has undergone radical neck dissection for the treatment of cancer. The nurse hears this sound when auscultating over the trachea. On the basis of this finding, the priority nursing action is to:
Contact the physician
Assess the client's pulse oximetry
Place the client in a supine position
Administer a nebulizer treatment with the use of a bronchodilator
A
The sound that the nurse hears is stridor. In the immediate postoperative period, the nurse assesses the client for stridor, a high-pitched musical sound heard on inspiration during auscultation over the trachea. This finding is reported immediately because it indicates airway obstruction. The client is placed in the Fowler position to facilitate breathing and promote comfort. Suctioning is performed to remove secretions that cannot be expectorated by the client. Pulse oximetry may be performed, but this is not the priority of the options provided. Administering a nebulizer treatment with a bronchodilator is not indicated at this time.
A pregnant woman is being admitted to the maternity unit. The woman tells the nurse that she felt a large gush of fluid from her vagina on the way to the hospital. The nurse detects a fetal heart rate of 90 beats/min. On physical examination, the nurse finds that the umbilical cord is protruding from the vagina. Which of the following actions should the nurse perform? Select all that apply.
Placing the woman in knee-chest position
Administering oxygen at 2 to 4 L/min by nasal cannula
Administering terbutaline (Brethine) to stop contractions
With two gloved fingers, exerting upward pressure, into the vagina, on the presenting part
Wrapping the cord loosely in a sterile towel saturated with warm sterile normal saline solution
A D E
When the umbilical cord is protruding, one of the first interventions the nurse should perform is to relieve compression of the cord by exerting upward pressure on the presenting part with two gloved fingers inserted vaginally. The cord must be protected from drying out and from becoming compressed. Therefore it should be wrapped with towels soaked in warm, sterile normal saline solution. The client is placed in an extreme Trendelenburg or modified Sims position or knee-chest position to ease compression. Oxygen should be administered by way of face mask at a rate of 8 to 10 L/min. A physician's prescription is needed for terbutaline, but this medication is usually not given in these circumstances. [Show Less]