Hurst Readiness Exam 2 (Latest 2023 – 2024) Graded A
What medication should the nurse anticipate giving to a client in preterm labor to stimulate
... [Show More] maturation of the baby's lungs?
1. Magnesium sulfate 2. Terbutaline 3. Methotrexate 4. Betamethasone - Rationale
4. Correct: Betamethasone is used to stimulate maturation of the baby's lungs in case preterm birth occurs. This medication is given to help prevent respiratory distress syndrome (RDS) by improving storage and secretion of surfactant that helps to keep the alveoli from collapsing. 1. Incorrect: Magnesium sulfate is given to stop preterm labor, however, if delivery is imminent, then Betamethasone should be given to stimulate maturation of the baby's lungs. 2. Incorrect: Terbutaline is contraindicated in preterm labor, however, if delivery is imminent, then Betamethasone should be given to stimulate maturation of the baby's lungs. 3. Incorrect: Methotrexate is used to stop the growth of the embryo in ectopic pregnancy so that the fallopian tube can be saved. It is not an agent used in the management of preterm labor.
An adult client has just returned to the nursing care unit following a gastroscopy. Which intervention should the nurse include on the plan of care?
1. Vital sign checks every 15 min x 4 2. Supine position for 6 hours 3. NPO until return of gag reflex 4. Irrigate NG tube every 2 hours 5. Raise four siderails - Rationale
1., & 3. Correct: Vital signs post procedure are important to monitor for any post-procedure complications such as bleeding or any signs of respiratory compromise. VS are checked frequently for the first hour post procedure. Any client who has a scope inserted down the throat and has received numbing medication in the back of the throat to depress the gag reflex should be kept NPO until the gag reflex returns. 2. Incorrect: Supine position for 6 hours is contraindicated. The HOB should be elevated. In the event the client vomits, he/she is less likely to aspirate with the HOB elevated. Supine position for 6 hours is used after a heart catheterization. 4. Incorrect: A client who is going for a gastroscopy procedure cannot have a nasal gastric tube. An NG tube would interfere with the procedure. 5. Incorrect: Raising all side rails is a form of restraint. Have the bed in low locked position. Raise three side rails, and have call light within reach.
A 70 year old client was admitted to the vascular surgery unit during the night shift with chronic hypertension. At 0830, the unlicensed nursing assistant (UAP) reports that the client's BP is 198/94. What would be the best action for the charge nurse to delegate at this time?
1. Ask the UAP to put the client back in bed immediately. 2. Tell the UAP to take the BP in the opposite arm in 15 minutes. 3. Have the LPN/LVN administer the 0900 furosemide and enalapril now. 4. Ask the LPN/LVN to assess the client for pain. - Rationale
3. Correct: The nurse should recognize the need for measures to reduce the blood pressure. Administering the client's blood pressure medicine is aimed at correcting the problem. It is appropriate to administer the medications at this time in relation to the time that the next dose is due. 1. Incorrect: This is an appropriate action, but does not address the problem of lowering the client's blood pressure. 2. Incorrect: This is an appropriate action, but does not address the problem of lowering the client's blood pressure. 4. Incorrect: This is an appropriate action, but does not address the problem of lowering the client's blood pressure.
A client suffers from migraine headaches. What assessment finding would the nurse expect to find during a migraine attack? [Show Less]