N201 EAQ #4

A woman in active labor arrives at the birthing unit. She tells the nurse that she was told that she had a chlamydial infection the last time she visited the clinic; however, she stopped taking the antibiotic after 3 days because she "felt better." In light of this history what would the nurse anticipate as part of the plan of care? 1. Administration of antibiotics before delivery 2. Oxytocin infusion to augment labor 3. Epidural anesthesia to relieve difficult labor discomfort 4. Magnesium sulfate infusion to prevent a precipitous birth

1

D5W/0.45 NS is infusing intravenously when a 7-year-old child is returned to the pediatric unit from surgery. The postoperative prescriptions do not indicate the desired rate of infusion. What is the most appropriate action for the nurse to take? 1. Reduce the flow rate to keep the vein open and obtain a prescription. 2. Adjust the flow rate to the 5 mL/hr that the child was receiving before surgery. 3. Maintain the current flow rate and call the nurse in the operating room to verify the rate. 4. Regulate the flow rate to 25 mL/hr until the healthcare provider arrives for follow-up observation.

1

A client who is suspected of having had a silent myocardial infarction has an electrocardiogram (ECG) prescribed by the primary healthcare provider. While the nurse prepares the client for this procedure, the client asks, "Why was this test prescribed?" Which is the best reply by the nurse? 1. "This test will detect your heart sounds." 2. "This test will reflect any heart damage." 3. "This procedure helps us change your heart's rhythm." 4. "The ECG will tell us how much stress your heart can tolerate."

2

A 7 lb, 4 oz (3289 g) boy is admitted to the nursery and placed in a warm crib. The neonate begins to choke on mucus. How should the nurse suction him with a bulb syringe? 1. By suctioning the mouth before the nostrils 2. By starting the oxygen and then suctioning the pharynx 3. By positioning the bulb far into the throat before beginning suctioning 4. By placing the bulb in the mouth, compressing the bulb, and starting suctioning

1

A client is admitted to the postanesthesia care unit after abdominal hysterectomy. Which assessment should the nurse report to the primary healthcare provider immediately? 1. Decreased urine output 2. Apical pulse of 90 beats/min 3. Increased drainage from the nasogastric tube 4. Serosanguineous drainage on the perineal pad

1

A depressed client tells a nurse, "I want to die." What is the most therapeutic response by the nurse? 1. "You would rather not live." 2. "You're not alone in feeling this way." 3. "When was the last time you felt this way?" 4. "Do you believe that there's life after death?"

1

A nurse is following the guidelines for high-quality documentation and reporting. Which guideline followed by the nurse while documenting factual records indicates a need for additional training? 1. "The client seems restless." 2. "The client states, 'I am worried.'" 3. "The client's pulse rate is 90 beats/min." 4. "The client has a body temperature of 39° C (102.2° F)."

1

A nurse overhears a client in a mental health hospital talking on the unit telephone. The conversation concerns a "fix" to be brought to the unit during visiting hours. The nurse knows that the client, who has a history of drug use, has a contract with the primary healthcare provider promising not to use street drugs while being treated in the inpatient unit. What is the best nursing intervention? 1. Phoning the client's primary healthcare provider and asking how the situation should be handled 2. Calling an immediate staff meeting to share the information and develop a plan for intervention 3. Calling security to make certain that hospital policies are enforced to maintain a safe environment 4. Confronting the client regarding the telephone conversation, then reporting the incident to the primary healthcare provider

2

After performing Leopold maneuvers on a laboring client, the nurse determines that the fetus is in the right occiput posterior (ROP) position. Where should the Doppler ultrasound transducer be placed to best auscultate fetal heart tones? 1. Above the umbilicus in the midline 2. Above the umbilicus on the left side 3. Below the umbilicus on the right side 4. Below the umbilicus near the left groin

3

A nurse has been working for the past 3 months with a 10-year-old child who has a diagnosis of conduct disorder. What is the best long-term outcome for this child? 1. Avoiding verbally aggressive behavior for 3 months 2.Verbalizing 10 alternative methods to address anger 3. Being sent to the principal's office less than three times in 5 weeks 4. Having no physically aggressive episodes during the next 3 months

4