NUR 1028 Exam 1
A woman who is pregnant for the first time is concerned about regaining her figure after the baby is born and wishes to diet during pregnancy. How should the nurse advise her? 1 Inadequate food intake can result in a low-birth-weight infant. 2 Dieting is recommended to decrease the risk of stillbirth. 3 Dieting is recommended to make the birthing process easier. 4 Inadequate food intake may result in gestational diabetes mellitus.
1 Inadequate food intake can result in a low-birth-weight infant. The recommended weight gain is at least 25 lb (11.3 kg) for this client; inadequate intake of nutrients during pregnancy results in an underweight newborn. The cause of stillbirth is usually not known; however, dieting during pregnancy is not recommended, because it can result in congenital anomalies, as well as low birth weight. Inadequate food intake is not a risk factor for gestational diabetes mellitus.
A post-dated pregnant client is admitted to the hospital for labor induction. Which medication would the primary healthcare provider prescribe? 1. Oxytocin 2. Nifedipine 3. Indomethacin 4. Methylergonovine
1. oxytocin Oxytocin is given to induce uterine contractions when normal labor does not occur in the final weeks of gestation. Nifedipine and indomethacin are used to control preterm labor. Methylergonovine is used to control postpartum hemorrhage.
Which statement made by a pregnant client to a nurse indicates that the client does not understand the teaching regarding fetal growth and development? 1 "The baby is smaller if the mother smokes." 2 "The baby gets food from the amniotic fluid." 3 "The baby's oxygen is provided by the mother." 4 "The baby's umbilical cord has two arteries and one vein."
2 "The baby gets food from the amniotic fluid." The amniotic fluid serves as a protective environment; the fetus depends on the placenta, along with the umbilical blood vessels, for nutrients and oxygen. "The baby is smaller if the mother smokes," "The baby's oxygen is provided by the mother," and "The baby's umbilical cord has two arteries and one vein" are all true statements, and further teaching would not be required.
A multipara is admitted to the birthing room in active labor. Her temperature is 98° F (36.7° C); pulse, 70 beats/min; respirations, 18 breaths/min; and blood pressure, 126/76 mm Hg. A vaginal examination reveals a cervix that is 90% effaced and 7 cm dilated with the vertex presenting at 2+ station. The client is complaining of pain and asks for medication. Which medication may cause respiratory depression in the newborn? 1 Naloxone 2 Lorazepam 3 Meperidine 4 Promethazine
3. Meperidine Meperidine is an opioid that can cause respiratory depression in the neonate if administered less than 4 hours before birth. Naloxone is an opioid antagonist that reverses the effects of respiratory depression in the newborn. Lorazepam is a sedative; it does not cause respiratory depression in the newborn, but it does not relieve pain by itself. Promethazine is a tranquilizer; it does not cause respiratory depression in the newborn. Promethazine does not relieve pain by itself.
A client is taking a progesterone oral contraceptive (minipill). The nurse instructs the client to take one pill daily during which point in the monthly cycle? 1 Five days of the ovulatory cycle 2 Latter part of the ovulatory cycle 3 First week of the menstrual cycle 4 Entire menstrual cycle
4. Entire menstrual cycle Maintenance of serum progesterone levels keeps cervical mucus thick and hostile to sperm at all times. Telling the client to take the pills for 5 days of the ovulatory cycle is inaccurate information; the pill must be taken throughout the menstrual cycle. Whereas progesterone oral contraceptives (minipills) must be taken throughout the cycle, combined estrogen and progesterone oral contraceptives are taken during the second, third, and fourth weeks of the cycle. Fertility drugs are often taken during the first part of the cycle to encourage ovulation, not for contraception.
While checking a blood bag prior to infusion, the nurse notes that the patient's blood type is A+ and the donor's blood type is O+. Which action would the nurse take? A. Administer the blood. B. Return the blood to the blood bank. C. Notify the physician. D. Ask the patient if anyone in the family has blood type A+.
A. Administer the blood. Rationale: A patient whose blood type is A+ can receive blood from a donor whose blood type is O+. The donor and recipient blood types are compatible, so there is no need to return the blood to the blood bank. The nurse would notify the physician only if the blood types were incompatible. These donor and recipient blood types are compatible. Trying to find a donor would be both inappropriate and unnecessary, since the patient and donor blood types are compatible.
What direction would the nurse provide to nursing assistive personnel (NAP) while establishing and maintaining a sterile field? A. "This work surface is too low. Choose a surface that's above your waist." B. "Begin to establish the sterile field here on the overbed table." C. "Be careful to touch only the outer 1-inch edge of the sterile drape." D. "Remember, reaching over the sterile field constitutes a break in sterile technique."
D. "Remember, reaching over the sterile field constitutes a break in sterile technique." In assisting the nurse during the procedure, the NAP might reach over the field if not reminded that doing so would constitute a break in sterile technique. The nurse cannot delegate the establishment of a sterile field to NAP.
The nurse is teaching a prenatal class regarding the risks of smoking during pregnancy. What neonatal consequence of maternal smoking should the nurse include in the teaching? 1 Low birthweight 2 Facial abnormalities 3 Chronic lung problems 4 Hyperglycemic reactions
1. Low birthweight Smoking during pregnancy causes a decrease in placental perfusion, resulting in a newborn who is small for gestational age (SGA). Facial abnormalities and developmental restriction may occur if the woman ingests alcoholic drinks during pregnancy, resulting in fetal alcohol syndrome. Smoking during pregnancy and chronic lung problems in newborns are not related. Maternal smoking may result in a SGA neonate; these neonates may experience hypoglycemia, not hyperglycemia.
Which action would the nurse perform to best ensure effective insertion of a venous access device into a patient's arm? A. Anchor the vein by placing a thumb 1 to 2 inches below the site. B. Insert the device tip at a 45-degree angle distal to the proposed site. C. Place the patient's left arm in a dependent position for 5 minutes before assessment. D. Apply a tourniquet to the left antecubital fossa 8 to 12 inches above the proposed site.
A. Anchor the vein by placing a thumb 1 to 2 inches below the site. Rationale: Anchoring the vein by placing a thumb 1 to 2 inches below the site stabilizes the vein, increasing the possibility of a successful insertion. The angle of insertion should be 10 to 30 degrees. Placing the patient's arm in a dependent position is directed toward improving visualization of the vein. Applying a tourniquet to the left antecubital fossa is directed toward improving visualization of the vein and should be applied 4 to 6 inches above the site.
What is the most important way in which the nurse can reduce the risk for infection in a patient with a CVAD that has a gauze dressing? A. Change the dressing every 48 hours. B. Apply sterile gloves to remove the original dressing. C. Cleanse the catheter and insertion site with sterile saline. D. Label the dressing with the date and time of application and the nurse's initials.
A. Change the dressing every 48 hours. Rationale: A gauze dressing on a CVAD should be changed every 48 hours and as needed. Doing so will reduce the patient's risk for infection. It is not necessary to wear sterile gloves to remove the soiled dressing. Cleansing the site with sterile saline will not minimize the patient's risk for infection. Labeling the dressing will not minimize the patient's risk for infection.
While checking a blood product prior to administration, the nurse is called away to assist with another procedure. What should the nurse do with the blood product? A. Return it to the blood bank until it can be administered. B. Ask another nurse to administer it to the patient. C. Ask nursing assistive personnel (NAP) to place it in the unit refrigerator if you expect to be gone less than 30 minutes. D. Leave it in the patient's room.
A. Return it to the blood bank until it can be administered. Rationale: An infusion of blood or blood products must be initiated within 30 minutes of obtaining the unit from the blood bank. If the infusion cannot be initiated within that period, the blood must be returned to the blood bank until the infusion can be initiated. Asking another nurse to administer blood or a blood product to the patient is unsafe practice, since two nurses need to check the blood product before administering it. In addition, the nurse who is caring for the patient is responsible for the safety of the infusion and therefore must be present for the infusion. The blood should not be placed in the unit refrigerator. Such an appliance is not intended to maintain a controlled temperature for proper storage of blood or blood products. The nurse should not leave the blood product in the patient's room, since there is no way to be certain how long it will take to assist with the other procedure. If the nurse does not return within 30 minutes, the blood will have been wasted.
Which action would the nurse take to minimize the patient's risk for infection when changing the dressing on a CVAD? A. Use sterile technique throughout the process. B. Apply a stabilization device if the initial sutures are no longer intact. C. Apply a mask to the patient during the procedure. D. Change the transparent dressing every 48 hours.
A. Use sterile technique throughout the process. Rationale: Using sterile technique throughout the dressing application will minimize the patient's risk for infection. Applying a stabilization device will not reduce the patient's risk for infection. A mask need not be applied to the patient when changing a CVAD. Transparent dressings are changed every 5 to 7 days and as needed.
The nurse is preparing equipment to administer a unit of blood to a patient. Which type of fluid would the nurse piggyback with the blood transfusion? A. 0.45% normal saline B. 0.9% normal saline C. Dextrose 5% and 0.45% normal saline D. Dextrose 5% and 0.9% normal saline
B. 0.9% normal saline Rationale: Blood and blood products can be administered only with 0.9% normal saline. No other solution is to be administered or piggybacked with blood or blood products. Only 0.9% normal saline solution, not 0.45% normal saline, can be used to administer blood. No other solution is to be administered or piggybacked with blood or blood products. Solutions that contain dextrose cause blood to coagulate and must not be administered or piggybacked with blood or blood products.
A patient is to receive one unit of packed red blood cells over 2 hours. Which rate is the usual flow rate for the first 15 minutes of a blood transfusion? A. 1 mL/min B. 2 mL/min C. 10 mL/min D. 25 mL/min
B. 2 mL/min Rationale: The nurse would infuse only 2 mL/min during the first 15 minutes of the blood transfusion. Transfusing the packed red blood cells at the rate of 1 mL/min is too slow. Transfusing the packed red blood cells at the rate of 10 mL/min is too fast. Only 2 mL/min is to infuse during the first 15 minutes of the blood transfusion. It would be appropriate to increase the rate to 25 mL/min after the first 15 minutes of the transfusion.
While preparing a sterile field, the nurse notes that a portion of the sterile drape has come into contact with the patient's gown. Which action is most appropriate in this situation? A. Place the sterile supplies only on the portion of the drape that did not touch the gown. B. Collect the supplies necessary and establish a new sterile field. C. Determine if the contact occurred within the outer 1-inch perimeter of the drape. D. Establish the sterile field on the opposite side of the drape.
B. Collect the supplies necessary and establish a new sterile field. Any breach in sterile technique requires the nurse to establish a new sterile field. The sterile drape must not touch anything as it is opened over the work surface. If sterile technique is broken, the sterile field must be reestablished.
How does the nurse evaluate the effect of nasotracheal suctioning on a patient's respiratory status? A. Asking the patient about symptoms of respiratory difficulty. B. Comparing respiratory assessment data from before and after the suctioning procedure. C. Confirming that the patient's pulse oximetry value is >90%. D. Auscultating the patient's chest after suctioning.
B. Comparing respiratory assessment data from before and after the suctioning procedure. Rationale: Comparing presuctioning and postsuctioning assessment data will provide the best measure of the procedure's efficacy. The patient may have needed suctioning without experiencing respiratory difficulty. The patient's normal pulse oximetry value may not be >90%. The nurse might be able to auscultate clear breath sounds; however, this information must be evaluated in light of presuctioning and postsuctioning assessment data to evaluate the procedure's efficacy.
The nurse is preparing to perform a sterile procedure for a patient. Which action will best minimize the risk of infection during the procedure? A. Administer a prophylactic antibiotic before the procedure, as prescribed. B. Follow sterile technique during the procedure. C. Ensure proper hand hygiene before the procedure. D. Educate the patient in order to minimize movement and talking during the procedure.
B. Follow sterile technique during the procedure. Sterile technique is intended to prevent the introduction of pathogens into the body. Antibiotics are not given to prevent infection during sterile procedures. Ensuring proper hand hygiene should be taken but is not as important as following sterile technique in minimizing the risk of infection during the procedure. Movement by the patient can create turbulent air flow that carries pathogens onto the field. Talking over the sterile field can also spread airborne microorganisms. Teaching the patient to move or talk as little as possible during the procedure, however, is not as important as following sterile technique.
As a nasotracheal catheter is inserted to suction the airway, a patient begins to gag and says, "I feel like I'm going to throw up." What is the nurse's best response? A. Complete the catheter insertion in 5 seconds or less. B. Remove the catheter. C. Encourage the patient to take several deep breaths to minimize the nausea. D. Stop advancing the catheter, and allow the patient to rest for several minutes.
B. Remove the catheter. Rationale: Gagging and nausea indicate that the catheter has probably entered the esophagus and must be removed. Attempting to complete the insertion could increase the gagging and nausea. Deep breathing is not the appropriate response to nausea when it occurs during insertion of a nasotracheal catheter. The catheter is probably in the esophagus and must be removed. Advancing the catheter after a period of rest will simply lead to more gagging and nausea.
Which statement might the nurse make to nursing assistive personnel (NAP) when caring for a patient with a dressed central venous access device (CVAD) site? A. "Assess the site frequently for signs of inflammation." B. "Be sure to change the transparent dressing on the site once every 7 days." C. "Let me know immediately if the patient's dressing becomes damp." D. "Make sure the patient knows to notify me if the site becomes painful or swollen."
C. "Let me know immediately if the patient's dressing becomes damp." Rationale: The task of reporting the need for a dressing change may be delegated to NAP. No aspect of CVAD assessment or patient education may be delegated to NAP. No aspect of CVAD insertion or dressing application may be delegated to NAP.
Which instruction might the nurse give to nursing assistive personnel (NAP) regarding the care of a patient with an intravenous access device? A. "Assess the IV site frequently for signs of inflammation." B. "Be sure not to obscure the insertion site with the dressing." C. "Let me know when you notice that the IV bag contains less than 100 milliliters." D. "Explain the symptoms of infection to the patient."
C. "Let me know when you notice that the IV bag contains less than 100 milliliters." Rationale: The task of reporting when the level of fluid in the IV bag is low may be delegated to NAP. Assessment skills may not be delegated to NAP. The skill of IV dressing application may not be delegated to NAP. Patient education may not be delegated to NAP.
An adult patient is prescribed to receive a unit of packed red blood cells. Which size intravenous catheter does the patient need to safely receive this blood? A. 30-gauge B. 25-gauge C. 18-gauge D. 10-gauge
C. 18-gauge Blood should be administered to an adult using a 14- to 24-gauge short peripheral catheter. The 30-gauge and 25-gauge catheters are too small. The 10-gauge catheter is too large and is not typically used for peripheral fluid or blood administration.
While suctioning the nasotracheal airway, the nurse notes that a patient's pulse rate has fallen from 102 bpm to 80 bpm. What is the best course of action? A. Encourage the patient to take several deep breaths. B. Interrupt suction to the catheter for at least 10 seconds. C. Discontinue suctioning by removing the suction catheter. D. Assess the patient's pulse oximetry reading to see if oxygenation is adequate.
C. Discontinue suctioning by removing the suction catheter. Rationale: A drop in pulse of 20 bpm or more necessitates discontinuation of suctioning and removal of the catheter. Deep breathing will not adequately address the patient's response. Pausing the suctioning briefly will not adequately address the patient's response. Taking an oximetry reading will not address the patient's response.
Why is it important to label the gauze dressing covering the site of an intravenous access device with the date, time, and nurse's initials? A. Reminds the nurse to document the insertion of the device B. Proves that the access site was assessed C. Informs the nurse and other staff when the next dressing change is due D. Reminds the nurse when to change the infusion tubing
C. Informs the nurse and other staff when the next dressing change is due Rationale: The gauze dressing over an intravenous access site must be changed every 48 hours. This is the reason for labeling the dressing with the date, time, and nurse's initials. The dressing is labeled in order to inform the nurse when the next dressing change is due. Labeling the dressing does not indicate that the access site was assessed. Intravenous infusion tubing has its own labeling.
The nurse is preparing to administer a unit of blood to a patient in the emergency department and discovers that he is not wearing an identification bracelet. What should the nurse do? A. Identify the patient by asking him to produce a photo ID, such as a driver's license. B. Administer the blood only if you have been caring for the patient and can be certain of his identity. C. Return the unit to the blood bank. D. Identify the patient by asking a family member to identify him.
C. Return the unit to the blood bank. Rationale: Since blood products must not be administered to any patient who is not wearing an identification bracelet, the nurse must return the unit to the blood bank. Even if the patient is conscious and awake, blood products must not be administered to any patient who is not wearing an identification bracelet. Blood products must not be administered to any patient who is not wearing an identification bracelet. Even if the patient has a family member in attendance, blood products must not be administered to any patient who is not wearing an identification bracelet.
Which of the following technique(s) is/are best for minimizing a patient's risk for injury when inserting a venous access device? A. Inserting the needle with the bevel up B. Using a vein on the dorsal surface of the arm C. Holding the skin taut directly below the site D. All of the above
D. All of the above Rationale: All of these actions will minimize injury to the patient. Inserting the needle bevel-up minimizes vein trauma by the needle itself. Use of adequate veins reduces the chance for rupture. Holding the skin taut directly below the site will decrease drag on insertion.
While preparing a sterile field, the nurse determines that additional supplies are needed. What will the nurse do to ensure that the sterile field is maintained? A. Cover the field with a sterile drape before leaving the room. B. Collect the necessary supplies after preparing a new sterile field. C. Retrieve the supplies, but instruct the patient not to touch anything on the field. D. Ask the assistant who has been helping with the procedure to bring the necessary supplies.
D. Ask the assistant who has been helping with the procedure to bring the necessary supplies. An assistant may be present while performing a procedure that requires maintaining a sterile field, and the assistant may add items to the field, provided correct technique is observed. Covering the field with a sterile drape will not ensure that asepsis is maintained. Any action that prevents the nurse from having constant visual contact with the field constitutes a break in sterile technique. The nurse would need to leave the field and begin again after collecting the necessary supplies. Responsibility for maintaining the sterile field cannot be delegated to the patient.
Which action is part of the preparation for nasotracheal suctioning? A. Place the patient in a supine position. B. Preoxygenate the patient with 100% oxygen. C. Suction 100 mL of warm tap water to flush the suction catheter. D. Place water-soluble lubricant onto the open sterile catheter package.
D. Place water-soluble lubricant onto the open sterile catheter package. Lubricant facilitates the insertion of the catheter. The patient should be in the semi-Fowler's position or sitting upright. Preoxygenation is not needed before nasotracheal suctioning. Sterile water or sterile 0.9% sodium chloride is used to flush the catheter.
What will the nurse do after removing the soiled dressing from a patient's CVAD device? A. Cleanse the site with soap and water. B. Use 2% chlorhexidine swabs to cleanse the site. C. Apply a skin protectant. D. Remove the catheter stabilization device, if present.
D. Remove the catheter stabilization device, if present. Rationale: The nurse would remove the catheter stabilization device, if present, after removing the soiled dressing. Soap and water is not used to cleanse the site of a central venous access device. The site is cleansed after the catheter stabilization device has been removed. Skin protectant is applied after cleansing the site.
A client who is admitted to the high-risk unit with severe preeclampsia anxiously asks the nurse, "Will my baby be all right?" How should the nurse respond? 1 "There is no way of telling at this time what the outcome will be." 2 "Your baby probably will be all right. It's protected by the amniotic fluid." 3 "If you follow your primary healthcare provider's instructions, everything will progress normally." 4 "We'll be constantly monitoring your baby's condition. I'll let you listen to the baby's heartbeat."
4 "We'll be constantly monitoring your baby's condition. I'll let you listen to the baby's heartbeat." Telling the client that the baby's condition will constantly be monitored reassures the client of the well-being of the fetus at the moment and indicates that the nurses are aware of and are monitoring the fetus's status. Saying that there is no way to know the outcome does not provide the mother with any reassurance of the status of the fetus or that anything is being done to monitor the fetus. Promising that the baby will be all right provides false reassurance; amniotic fluid will not protect the fetus if the mother has a seizure. Suggesting that everything will progress normally if the client follows the primary healthcare provider's instructions provides false reassurance; following instructions does not guarantee a healthy newborn.
The partner of a woman in labor is having difficulty timing the frequency of contractions and asks the nurse to review the procedure. How should contractions be timed? 1 From the end of one contraction to the end of the next contraction 2 From the end of one contraction to the beginning of the next contraction 3 From the beginning of one contraction to the end of the next contraction 4 From the beginning of one contraction to the beginning of the next contraction
4 From the beginning of one contraction to the beginning of the next contraction The frequency of contractions is timed from the beginning of one contraction to the beginning of the next; this is the definition of one contraction cycle. The beginning, not the end, of a contraction is the starting point for timing the frequency of contractions. The time between the end of one contraction and the beginning of the next contraction is the interval between contractions. Timing from the beginning of one contraction to the end of the next contraction is too long a timeframe and will produce inaccurate information.
While a client is being given intravenous magnesium sulfate therapy for preeclampsia, it is essential for the nurse to monitor the client's deep tendon reflexes. What reason does the nurse give to the client to explain why this is done? 1. Reveals her level of consciousness 2. Reveals the mobility of the extremities 3. Reveals the response to painful stimuli 4. Identifies the potential for respiratory depression
4. Identifies the potential for respiratory depression Respiratory distress or arrest may occur when the serum level of magnesium sulfate reaches 12 to 15 mg/dL. Deep tendon reflexes disappear when the serum level is 10 to 12 mg/dL. The medication is withheld in the absence of deep tendon reflexes. The therapeutic serum level of magnesium sulfate is 5 to 8 mg/dL. Deep tendon reflexes do not reveal a client's level of consciousness, mobility of the extremities, or the response to painful stimuli. Deep tendon reflexes can be associated with muscle strengthening.
A patient received two 300-mL units of packed red blood cells, and the line was flushed with 25 mL of solution between the units. What is the total amount of fluid the nurse will document having provided to the patient? A. 675 mL B. 650 mL C. 625 mL D. 600 mL
C. 625 mL Rationale: Two units of 300 mL each totals 600 mL of blood. In addition, 25 mL of 0.9% normal saline solution was used to flush the line between the units. Adding the blood and the saline together yields 625 mL of fluid. The nurse will document that amount.
Which response would the nurse report immediately if it occurred in association with nasotracheal suctioning? A. Patient complains of discomfort during the procedure. B. Patient has a severe bout of nonproductive coughing and complains of sore throat. C. After oxygen delivery device has been reapplied on completion of the procedure, patient's pulse oximetry reading falls to 88%. D. Patient's pulse rate increases by 10 bpm.
C. After oxygen delivery device has been reapplied on completion of the procedure, patient's pulse oximetry reading falls to 88%. Rationale: This decline in peripheral blood oxygen saturation must be reported. It represents a decline in the patient's condition following a procedure that should have improved his or her SpO2 reading. Discomfort need not be reported. Symptoms of coughing and sore throat do not require immediate reporting. This change in heart rate is anticipated with the procedure. Taken by itself, it does not require reporting.
What is the most important step the nurse can take to minimize the risk of tearing a sterile glove when applying it to the hands? A. Using powdered sterile gloves B. Keeping the fingernails trimmed and smoothly filed C. Selecting the proper glove size D. Drying the hands thoroughly before applying the gloves
C. Selecting the proper glove size Improper glove size is the leading cause of glove tears. Most sterile gloves are powdered. Since using unpowdered gloves is usually not an option, using powdered gloves does not reduce the risk of tearing a sterile glove. Keeping the fingernails well-trimmed and smoothly filed is prudent, but it is not the most important step the nurse can take to reduce the risk of tearing a glove. Drying the hands thoroughly before applying gloves is prudent, but it is not the most important step the nurse can take to reduce the risk of glove tears.
Which protocol does not vary among institutions? A. Acceptability of wearing artificial nails in patient care areas B. Use of impervious transparent dressings to cover open lesions on nurse's hands during sterile procedures C. Use of sterile gloves for sterile procedures D. Sterile gloves are only available in "one size fits all"
C. Use of sterile gloves for sterile procedures By definition, a procedure is not sterile if sterile gloves are not worn. Many, but not all, health care institutions prohibit artificial nails and extenders in clinical areas. Review your agency's policy before performing a sterile procedure. In some settings, nurses are allowed to cover open lesions with a sterile, impervious, transparent dressing. In other settings, the presence of such a lesion may prevent the nurse from participating in a sterile procedure. Review your agency's policy before performing a sterile procedure. Sterile gloves are available in various sizes, such as 6½ and 7. The availability of gloves will vary among institutions.
The nurse is caring for a pregnant client who is undergoing an ultrasound examination during the first trimester. The nurse explains that an ultrasound during the first trimester is utilized in order to do what? 1 Estimate fetal age 2 Detect hydrocephalus 3 Rule out congenital defects 4 Approximate fetal linear growth
1. Estimate fetal age Measurement of the crown-rump length (CRL) is useful in approximating fetal age in the first trimester. Hydrocephalus cannot be detected during the first trimester. Ultrasonography is used to detect structural defects in the second trimester. It is too early in this pregnancy to determine fetal linear growth.
A client at 38 weeks' gestation is admitted for induction of labor. Her membranes ruptured 12 hours ago. There are no other signs of labor. Which medication does the nurse anticipate will be prescribed? 1 Oxytocin 2 Estrogen 3 Ergonovine 4 Progesterone
1. Oxytocin Oxytocin is a small-polypeptide hormone synthesized in the hypothalamus and secreted from the neurohypophysis (posterior pituitary gland) during parturition or suckling; it promotes powerful uterine contractions and is therefore used to induce labor. Estrogen suppresses follicle-stimulating and luteinizing hormones, thereby helping maintain a pregnancy. Ergonovine can induce sustained contractions, which is contraindicated during labor; it may be prescribed in the postpartum period to promote or maintain a contracted uterus. Progesterone causes hyperplasia of the endometrium in preparation for implantation of the fertilized ovum; later it helps maintain the pregnancy.
A pregnant client with diabetes is referred to the dietitian in the prenatal clinic for nutritional assessment and counseling. What should the nurse emphasize when reinforcing the client's dietary program? 1 The need to increase high-quality protein and decrease fats 2 The need to increase carbohydrates to meet energy demands and prevent ketosis 3 The need to eat a low-calorie diet that maintains the current insulin coverage and helps prevent hyperglycemia 4 The need to eat a pregnancy diet that meets increased dietary needs and to adjust the insulin dosage as necessary
4. The need to eat a pregnancy diet that meets increased dietary needs and to adjust the insulin dosage as necessary Increased metabolic demands on the body during pregnancy require increased ingestion of calories; appropriate doses of insulin must be provided to permit glucose utilization by the body. The quantities of carbohydrates and fats, as well as of protein, are increased, not decreased, during pregnancy. Simply increasing carbohydrate intake is not sufficient to prevent ketosis. A low-calorie diet is contraindicated; it will not meet the demands of pregnancy on the client's body or the needs of the growing fetus.
Why might the nurse offer the patient a bedpan before establishing a sterile field? A. Anticipating what the patient might need during a lengthy sterile procedure will minimize patient movement. B. A patient's becoming incontinent constitutes a breach in sterile technique. C. Refocusing the patient's attention on a task decreases anxiety. D. Assessing the patient's ability to follow instructions will help the nurse maintain the sterile field.
A. Anticipating what the patient might need during a lengthy sterile procedure will minimize patient movement. Some procedures that require asepsis are lengthy, and it is helpful to anticipate the patient's needs. A patient's becoming incontinent does not constitute a breach in sterile technique. Although refocusing the patient's attention may decrease anxiety, a patient would not be asked use a bedpan as a means of distraction. Asking the patient to follow a few simple commands usually yields enough information for the nurse to determine how well the patient can follow instructions. The patient would not be asked to use a bedpan for that purpose.
The nursing assistive personnel (NAP) reports to the nurse that a patient's intravenous access device dressing is wet. What would the nurse do first? A. Assess the site. B. Instruct the NAP on how to change the dressing. C. Remove the device, and insert a new one. D. Reinforce the dressing with more gauze.
A. Assess the site. Rationale: The nurse would first assess the site to check for infiltration and to see if the IV has become dislodged. The nurse may not delegate to NAP the changing of dressing on an intravenous device. The device may not need to be removed and reinserted. Reinforcing the dressing is not sufficient.
Which action will the nurse take to minimize a patient's risk for injury when applying a gauze dressing to an infusion site? A. Avoid encircling the arm with tape B. Not secure the tubing and catheter hub with tape C. Secure the tubing in two different locations on the arm D. Label the dressing with the date and time of application
A. Avoid encircling the arm with tape Rationale: The nurse will avoid encircling the arm with tape, because doing so can impede circulation in the arm. Failing to secure the tubing and catheter could increase the patient's risk for injury. Securing the tubing in two different locations on the arm will not minimize the patient's risk for injury. Labeling the dressing with the date and time of application will not minimize the patient's risk for injury.
How might the nurse prepare a patient to anticipate some discomfort when inserting a venous access device? A. Instruct the patient to expect a sharp, quick stick. B. Insert the access device as quickly as possible. C. Apply a topical anesthetic to the area before inserting the device. D. Promise that the procedure will not hurt once the device has been inserted.
A. Instruct the patient to expect a sharp, quick stick. Rationale: Educating the patient to have reasonable expectations about the possible discomfort will best prepare him or her for it. Inserting the access device as quickly as possible will not prepare the patient regarding what to expect. Applying a topical anesthetic will reduce the likelihood of pain; however, this is not routinely done when inserting a venous access device. It is inappropriate to make such a promise.
After applying sterile gloves, the patient states she is uncomfortable and would like to move to her left side. What is the best way for the nurse to keep the gloves sterile while waiting for nursing assistive personnel (NAP) to position the patient for a sterile dressing change? A. Interlocking the fingers and keeping the hands above waist level B. Keeping the arms at the sides, with elbows bent and gloved hands pointing up C. Leaving the room momentarily D. Stepping back from the bedside where NAP are working
A. Interlocking the fingers and keeping the hands above waist level Once the gloves have been applied, the fingers should be interlocked and held in front of the body above waist level. Keeping the arms at the sides, with elbows bent and gloved hands pointing up is not appropriate sterile technique. Leaving the room is not appropriate; the nurse will stay in the treatment area after gloving. Stepping back from the bedside and other traffic areas is prudent, since turbulent air can contaminate gloves, but it is not the most important step the nurse can take to keep gloves sterile.
Which action will the nurse take to minimize a patient's risk for injury when applying a dressing to an infusion site? A. Use aseptic technique throughout the process. B. Apply a skin protectant to the skin before the intervention. C. Apply a transparent dressing that allows for visualization of the site. D. Explain the process to the patient before implementation.
A. Use aseptic technique throughout the process. Rationale: Following aseptic technique throughout the dressing application will minimize the patient's risk for injury related to infection. Applying a skin protectant will not minimize the patient's risk for injury. Being able to visualize the infusion site will not minimize the patient's risk for injury. Patient teaching before the procedure will not minimize the patient's risk for injury.
When are sterile nonlatex gloves recommended for a sterile procedure? A. When there is a possible sensitivity issue B. When the staff member prefers them C. When latex gloves are not conveniently available D. When the patient prefers them
A. When there is a possible sensitivity issue The possibility of a serious allergic reaction to latex necessitates the use of nonlatex gloves when the patient or nurse is sensitive to latex. Staff preference is not a reason to select nonlatex sterile gloves. Staff should use latex gloves unless there is a sensitivity issue. Unless the patient has a known latex allergy, he or she is not usually consulted regarding the type of glove a staff member uses.
How can the nurse minimize the risk of dislodging the catheter when removing a dressing? A. Lower the patient's head during the dressing change. B. Remove the transparent dressing or tape and gauze in the direction of catheter insertion. C. Apply skin protectant while the stabilization device is off. D. Cleanse the insertion site quickly and gently in concentric circles.
B. Remove the transparent dressing or tape and gauze in the direction of catheter insertion. The old dressing should be removed in the direction of catheter insertion. Positioning the patient with his or her head lower will not reduce the risk of dislodging the catheter during a dressing change. Skin protectant should be applied before placing a new catheter stabilization device. However, doing so will not reduce the risk of dislodging the catheter. The site should be cleansed using a back-and-forth motion vertically and horizontally for at least 30 seconds. However, following this technique will not reduce the risk of dislodging the catheter.
When applying a dressing to an infusion site on a patient's left forearm, what will the nurse do to ensure proper maintenance of the tubing? A. Apply a transparent dressing to the insertion site. B. Use a catheter stabilizing device when applying the dressing. C. Apply the dressing distal to the tubing and catheter hub connector. D. Secure the tubing to the patient's dressing with 1-inch tape.
C. Apply the dressing distal to the tubing and catheter hub connector. Rationale: Applying the dressing proximal to the tubing and catheter hub connector will allow the tubing to be disconnected and changed when indicated. Use of a transparent dressing does not address maintenance of the tubing. Use of a catheter stabilizing device does not address maintenance of the tubing. Securing the tubing to the patient's dressing with 1-inch tape is not recommended because it would hinder the view of the insertion site.
Which action would the nurse perform first when preparing to apply sterile gloves? A. Perform hand hygiene. B. Place the package on a stable, flat surface. C. Assess the glove packaging for wetness or tears. D. Open the outer packaging.
C. Assess the glove packaging for wetness or tears. The nurse first assesses the packaging for wetness or tears; any breach in the packaging compromises the sterility of the gloves. The nurse performs hand hygiene after selecting the gloves and placing them on the work surface. The nurse places the package of gloves on the work surface after inspecting the integrity of the package. The nurse opens the outer packaging after inspecting the integrity of the packaging, placing the package on the work surface, and performing hand hygiene.
A patient is to receive 3 units of packed red blood cells over 8 hours. What will the nurse do to maintain the patency of the patient's IV access line after each of the first two units of blood has transfused? A. Infuse 0.9% normal saline at 100 mL/hour. B. Infuse dextrose 5% and 0.9% normal saline at the KVO (keep-vein-open) rate. C. Infuse 0.9% normal saline at the KVO rate. D. Cap the intravenous line.
C. Infuse 0.9% normal saline at the KVO rate. Rationale: When consecutive units are to be given, the patency of the IV line is maintained with 0.9% normal saline infusing at the KVO rate. Normal saline 0.9% is the correct solution, but an infusion rate of 100 mL/hr is too fast. Any solution containing dextrose is incompatible with blood and must not be infused into the same line used for blood or blood products. Capping the intravenous line will not maintain its patency between units of blood.
The nurse is inserting an over-the-needle catheter into a newly admitted patient. What will the nurse do after confirming blood return? A. Loosen or remove the tourniquet. B. Advance the catheter 1 inch into the vein. C. Lower the catheter until it is flush with the skin. D. Thread the catheter into the vein up to the hub.
C. Lower the catheter until it is flush with the skin. Rationale: Lowering the catheter until it is flush with the skin minimizes the risk of passing the needle through the opposite vessel wall. The tourniquet is loosened or removed later in the procedure. This is done later in the procedure. Threading the catheter into the vein up to the hub is done later in the procedure.
While checking a blood product prior to administration, the nurse notices that the birth date on the blood bag and requisition do not match the birth date on the patient's identification bracelet. Which is the correct action for the nurse to take? A. Be especially vigilant for adverse reactions during the infusion. B. Ask the patient to state his or her birth date. C. Correct the birth date on the blood bag and requisition. D. Return the blood to the blood bank.
D. Return the blood to the blood bank. Rationale: If there is any discrepancy in the patient's birth date or other identifying information, the product must not be administered. Notify the blood bank and other appropriate personnel, as indicated by your agency's policy. Return the blood to the blood bank until the discrepancy has been resolved. If there is any discrepancy in the patient's birth date or other identifying information, the product must not be administered. Asking the patient to state his or her birth date will not correct the discrepancy between the identifying information on the blood bag and requisition and the information on the patient's identification bracelet. It would be inappropriate to alter the birth date on the blood bag and on the requisition.
A patient prescribed to receive two units of packed red blood cells is to receive a dose of intravenous medication between the two units. How would the nurse administer the medication? A. In the IV line for the blood product during the transfusion B. In the IV line for the blood product when the line is flushed with normal saline C. In oral form D. Through another IV line
D. Through another IV line Rationale: The nurse would maintain a separate access line if IV solutions or medications are to be administered. Medication is never injected into the same IV line used for a blood component. The blood product may be incompatible with the medication, and the blood component could become contaminated if the same IV line is used for another purpose. Medication is never injected into the same IV line used for a blood component. The blood product may be incompatible with the medication, and the blood component could become contaminated if the same IV line is used for another purpose. Medication is never injected into the same IV line used for a blood component. The blood product may be incompatible with the medication, and the blood component could become contaminated if the same IV line is used for another purpose. The prescribed medication is to be given intravenously. The nurse cannot change the form of the medication that has been ordered.