Implementation
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Question 1 of 5.
A client begins to experience seizure activity while in bed. The nurse should provide which intervention to prevent aspiration?
A. Raise the head of the bed.
B. Loosen restrictive clothing.
C. Remove the pillow and raise the padded side rails.
D. Position the client on the side with the head flexed forward.
Explanation: Positioning the client on one side with the head flexed forward allows the tongue to fall forward and facilitates the drainage of secretions, which could help prevent aspiration. The nurse would not raise the head of the client's bed. The nurse would remove restrictive clothing and the pillow and raise the padded side rails, if present, but these actions would not decrease the risk of aspiration; rather, they are general safety measures to use during seizure activity.
Question 2 of 5.
A client diagnosed with heart failure is receiving furosemide and digoxin daily. When the nurse enters the room to administer the morning doses, the client reports anorexia, nausea, and yellow vision. Which intervention should the nurse implement first?
A. Administer the medications.
B. Contact the primary health care provider.
C. Check the morning serum digoxin level.
D. Check the morning serum potassium level.
Explanation: The nurse should check the result of the digoxin level that was drawn because the client's symptoms are compatible with digoxin toxicity. A low potassium level may contribute to digoxin toxicity, so checking the serum potassium level may give useful additional information, but the digoxin level should be checked first. The medications should be withheld until both levels are known. If the digoxin level is elevated or the potassium level is not within the normal range, then the primary health care provider should be notified. If the morning digoxin level is within the therapeutic range, then the client's complaints are unrelated to the digoxin.
Question 3 of 5.
The nurse is checking the fundus of a postpartum woman and notes that the uterus is soft and spongy. Which nursing action is appropriate initially?
A. Encourage the mother to ambulate.
B. Notify the primary health care provider.
C. Massage the fundus gently until it is firm.
D. Document fundal position, consistency, and height.
Explanation: If the fundus is boggy (soft), it should be massaged gently until it is firm and the client is observed for increased bleeding or clots. Option 1 is an inappropriate action at this time. The nurse should document the fundal position, consistency, and height; the need to perform fundal massage; and the client's response to the intervention. The primary health care provider will need to be notified if uterine massage is not helpful.
Question 4 of 5.
A primipara is being evaluated in the clinic during her second trimester of pregnancy. The nurse checks the fetal heart rate (FHR) and notes that it is 190 beats/min. What is the appropriate initial nursing action?
A. Document the finding.
B. Tell the client that the FHR is fast.
C. Consult with the primary health care provider.
D. Recheck the FHR with the client in the standing position.
Explanation: The FHR should be between 120 and 160 beats/min. In this situation, the FHR is elevated from the normal range, and the nurse should consult with the primary health care provider. The FHR would be documented, but option 3 is the appropriate action. The nurse would not tell the client that the FHR is fast at this point in time. Option 4 is an inappropriate action.
Question 5 of 5.
A client tells the clinic nurse that her skin is very dry and irritated. Which product should the nurse suggest that the client apply to the dry skin?
A. Myoflex
B. Aspercreme
C. Topical emollient
D. Acetic acid solution
Explanation: A topical emollient is used for dry, cracked, and irritated skin. Aspercreme and Myoflex are used to treat muscular aches. Acetic acid solution is used for irrigating, cleansing, and packing wounds infected with Pseudomonas aeruginosa.
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