Nursing Elites

1. For which adverse effect of the block does the postpartum nurse monitor the woman after receiving a subarachnoid (spinal) block for a cesarean delivery?

• A. Headache
• B. Pruritus
• C. Vomiting
• D. Hypertension

Correct answer: A

Rationale: The correct answer is 'Headache.' Postdural headache is a common adverse effect associated with a subarachnoid block due to cerebrospinal fluid leakage at the site of dural puncture. This headache worsens when the woman is upright and may improve when she lies flat. To manage this headache, bed rest and adequate hydration are recommended. Pruritus, vomiting, and hypertension are not typically associated with subarachnoid blocks. Pruritus, nausea, and vomiting are more commonly linked to the use of intrathecal opioids.

2. After applying oxygen using bi-nasal prongs to a client who is having chest pain, the nurse should implement which intervention?

• A. Have the client take slow deep breaths in through their mouth and out through their nose.
• B. Post signs indicating that oxygen is in use on the client's door and in their room
• C. Apply Vaseline petroleum to both nares and 2 by 2 gauze around the oxygen tubing at the client's ears
• D. Encourage the client to hyperextend the neck, take a few deep breaths and cough.

Correct answer: A

Rationale: After applying oxygen using bi-nasal prongs to a client with chest pain, it is essential for the nurse to post signs indicating that oxygen is in use on the client's door and in their room. This safety precaution alerts healthcare providers and visitors that the client is receiving oxygen therapy, reducing the risk of accidents or misunderstandings. Choice A is incorrect because instructing the client to take slow deep breaths is not the appropriate intervention after applying oxygen. Choice C suggests applying Vaseline and gauze, which is unnecessary and not a standard practice. Choice D advising the client to hyperextend the neck, take deep breaths, and cough is not indicated after applying oxygen therapy and could potentially be harmful.

3. A woman is in the active phase of labor. An external monitor has been applied, and a fetal heart deceleration of uniform shape is observed, beginning just as the contraction is underway and returning to the baseline at the end of the contraction. Which of the following nursing actions is most appropriate?

• A. Administer O2 if necessary.
• B. Turn the client on her left side.
• C. Notify the physician.
• D. No action is necessary.

Correct answer: D

Rationale: The correct answer is 'No action is necessary.' In this scenario, the fetal heart deceleration of uniform shape observed is an early deceleration resulting from head compression. Early decelerations are benign and typically do not require any intervention as they mirror the contraction pattern. It is essential to closely observe both the mother and the baby. Administering O2 (Choice A) is not necessary as early decelerations do not indicate fetal distress. Turning the client on her left side (Choice B) is not required for early decelerations. Notifying the physician (Choice C) is not needed for this type of deceleration, as it is a normal response to head compression during labor.

4. The client has been taking divalproex (Depakote) for the management of bipolar disorder. The nurse should give priority to monitoring which laboratory test?

• A. Alanine aminotransferase (ALT)
• B. Serum glucose
• C. Serum creatinine
• D. Serum electrolytes

Correct answer: A

Rationale: The correct answer is Alanine aminotransferase (ALT). Monitoring ALT levels is crucial when a patient is taking divalproex (Depakote) due to the risk of drug-induced hepatitis. Elevated ALT levels indicate liver damage or disorders, which can be a side effect of Depakote. Serum glucose (choice B) is not the priority for monitoring in this case, as the medication does not directly affect glucose levels. Serum creatinine (choice C) is not the most relevant test to monitor for Depakote use; it primarily assesses kidney function. Serum electrolytes (choice D) are important but do not take precedence over monitoring ALT levels when a patient is on Depakote.

5. Which is an example of a sentinel event?

• A. The terminally ill client is referred to hospice and dies 3 months later.
• B. A client receives an unordered mammogram which reveals a small cyst.
• C. A client with a laceration to the knee requiring 4 sutures falls when getting up unassisted after being instructed to remain in bed.
• D. A client scheduled for knee replacement surgery had an above-the-knee amputation performed.

Correct answer: D

Rationale: Yes! A sentinel event is an unexpected occurrence causing death or serious injury. In this case, a client who was scheduled for knee replacement surgery but had an above-the-knee amputation performed instead represents a sentinel event as it resulted in serious harm that was not intended. The other choices do not meet the criteria for a sentinel event. Choice A describes a natural progression for a terminally ill client, choice B shows an incidental finding from a test, and choice C involves a preventable fall leading to an injury but not a sentinel event.

Similar Questions