1. The nurse asks the client with an epidural anesthesia to void every hour during labor. The rationale for this intervention is:
A. The sensation of the bladder filling is diminished or lost.
B. Her level of consciousness is altered.
C. The bladder fills more rapidly because of the medication used for the epidural.
D. She is embarrassed to ask for the bedpan that frequently
A. The sensation of the bladder filling is diminished or lost.
B. Her level of consciousness is altered.
C. The bladder fills more rapidly because of the medication used for the epidural.
D. She is embarrassed to ask for the bedpan that frequently
Answer A is correct. Epidural anesthesia decreases the urge to void and sensation of a full bladder. A full bladder decreases the progression of labor. Answers A, B, and D are incorrect because the bladder does not fill more rapidly due to the epidural, the client is not in a trancelike state, and the client’s level of consciousness is not altered, and there is no evidence that the client is too embarrassed to ask for a bedpan.
2. The nurse is caring for a 9-year-old child admitted with asthma. Upon the morning rounds, the nurse finds an O2 sat of 78%. Which of the following actions should the nurse take first?
A. Notify the physician
B. Apply oxygen
C. Assess the child’s pulse
D. Do nothing; this is a normal O2 sat for a 9-year-old
Answer B is correct. Remember the ABC’s (airway, breathing, circulation) when answering this question. Before notifying the physician or assessing the child’s pulse, oxygen should be applied to increase the child’s oxygen saturation. The normal oxygen saturation for a child is 92%–100%. Answer A is important but not the priority, answer B is inappropriate, and answer D is also not the priority.
3. The nurse is caring for a 6-year-old client admitted with the diagnosis of conjunctivitis. Before administering eyedrops, the nurse should recognize that it is essential to consider which of the following?
A. Allow the mother to instill the eyedrops.
B. The child should be allowed to instill his own eyedrops.
C. The eye should be cleansed with warm water, removing any exudate, before instilling the eyedrops.
D. If the eye is clear from any redness or edema, the eyedrops should be held.
Answer C is correct. Before instilling eyedrops, the nurse should cleanse the area with warm water. A 6-year-old child is not developmentally ready to instill his own eyedrops, so answer B is incorrect. The mother cannot be allowed to administer the eye drops in the hospital setting so answer C incorrect. Although the eye might appear to be clear, the nurse should instill the eyedrops, as ordered (answer D).
4. The nurse is caring for a client admitted to labor and delivery. The nurse is aware that the infant is in distress if she notes:
A. Contractions every three minutes
B. Absent variability
C. Fetal heart tone accelerations with movement
D. Fetal heart tone 120–130 bpm
A. Notify the physician
B. Apply oxygen
C. Assess the child’s pulse
D. Do nothing; this is a normal O2 sat for a 9-year-old
Answer B is correct. Remember the ABC’s (airway, breathing, circulation) when answering this question. Before notifying the physician or assessing the child’s pulse, oxygen should be applied to increase the child’s oxygen saturation. The normal oxygen saturation for a child is 92%–100%. Answer A is important but not the priority, answer B is inappropriate, and answer D is also not the priority.
3. The nurse is caring for a 6-year-old client admitted with the diagnosis of conjunctivitis. Before administering eyedrops, the nurse should recognize that it is essential to consider which of the following?
A. Allow the mother to instill the eyedrops.
B. The child should be allowed to instill his own eyedrops.
C. The eye should be cleansed with warm water, removing any exudate, before instilling the eyedrops.
D. If the eye is clear from any redness or edema, the eyedrops should be held.
Answer C is correct. Before instilling eyedrops, the nurse should cleanse the area with warm water. A 6-year-old child is not developmentally ready to instill his own eyedrops, so answer B is incorrect. The mother cannot be allowed to administer the eye drops in the hospital setting so answer C incorrect. Although the eye might appear to be clear, the nurse should instill the eyedrops, as ordered (answer D).
A. Contractions every three minutes
B. Absent variability
C. Fetal heart tone accelerations with movement
D. Fetal heart tone 120–130 bpm
4th ans
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