Medication
Nursing Actions
Nursing Interventions
Delegation
Marie's History & Misc.
100
1. Prior to discontinuing the IV pitocin (oxytocin) which assessment is most important for the nurse to obtain? a. Vital Signs b. Vaginal Discharge c. Uterine Firmness d. Oral Intake
What is "C" uterine firmness.
100
3. What is the priority nursing action to address Marie's needs related to the repair of her 4th degree perineal laceration? a. Provide prescribed oral pain medication and stool softner b. Encourage warm sitz baths 2 to 3 times daily c. Apply perineal ice packs consistently for the first 24 to 48 hours d. Teach proper and frequent use of the peri-bottle
What is "C", apply perineal ice packs consistently for the first 24 to 48 hours
100
Marie's status changes while her husband went home to be with the other children. Marie states that she doesn't want her children to see her this way and asks the nurse to tell Mr. Wilson what has happened (change in status related to vaginal bleeding). 13. What intervention should the nurse implement to communicate the situation to Marie's condition? a. Ask the unit clerk to notify Mr. Wilson about Marie's change in condition, but let him know that she is going to be all right. b. Call Mr. Wilson from the nurses' station to inform him of his wife's status and request that he come to the hospital soon, without the children. c. Dial the telephone number for Marie and hold the phone for her, allowing her to talk to her husband and explain what happened. d. Wait until Mr. Wilson arrives at the hospital with the children, and talk to him before he goes in to see his wife.
What is "B", call Mr. Wilson from the nurses' station to inform him of his wife's status and request that he come to the hospital soon, without the children.
100
8. Which task is best delegated to the UAP during this crisis (vaginal bleeding)? a. Bring IV fluids and supplies from the supply room b. Change the bed linens and bathe the client c. Start o2 per nasal cannula d. Obtain the vital signs and o2 saturation
What is "D" obtain the vital signs and o2 saturation
100
12. Considering the client’s history, what etiology is most likely? a. Perineal laceration b. Retained placental parts c. Uterine atony d. Coagulopathy
What is "C", uterine atony
200
9. How many mL of oxytocin should the nurse draw up in the syringe to inject into the 1000mL bag of normal saline? a. 1mL b. 10mL c. 4mL d. 0.04 mL
What is "a" 1mL.
200
Fifteen minutes after the initial assessment, the nurse finds Marie disoriented and lying on her back in a pool of vaginal blood, with the sheets beneath her saturated with blood. What is the priority nursing action? a. Massage the fundus b. Take vital signs c. Increase the IV rate d. Check the bladder
What is "A", Massage the fundus
200
Marie's nurse is getting ready to administer the first unit of blood when the nursery nurse brings in Marie's infant son and states that Marie needs to feed him because it has been 4 hours since the infant last nursed. The infant is sleeping soundly in the crib. 15. What is the best thing for Marie's nurse to do? a. Encourage Marie to nurse the infant while proceeding with the blood transfusion b. Delay hanging the blood for 15 to 20 minutes until Marie finishes nursing the infant c. Request that the infant be brought back in an hour to give the blood time to take effect d. Explain Marie's history and request that the infant be fed with formula in the nursery
What is "D", Explain Marie's history and request that the infant be fed with formula in the nursery
200
19. Considering Marie’s history and acuity level, who is the best nurse to assign to Marie’s care? a. Registered nurse (RN) who has been licensed for 9 months b. Labor and delivery nurse with 12 years of experience, who was called in to work for 4 hours until 2300 c. Licensed practical nurse (LPN) with 15 years of postpartum/nursery experience d. Charge nurse with 5 years experience who oversees care during the night shift and carries ½ of the client assignment load until 2300
What is "B", labor and delivery nurse with 12 years of experience, who was called in to work for 4 hours until 2300
200
4. Considering Marie’s history, which postpartal complication is she most at risk for? a. Endometritis b. Subinvolution c. Deep vein thrombosis d. Hemorrhage
What is "D", hemorrhage
300
11. Which finding is most indicative that the medication is reaching a theraputic level? a. BP of 74/44 b. HR of 94 c. O2 sat of 85% d. Firm fundus
What is "D" firm fundus.
300
After finding Marie in a pool of vaginal blood and after the nurse massages the fundus and calls for help: 7. While waiting for help to arrive, what is the next priority action? a. Obtain vital signs b. Apply oxygen c. Assess for bladder distension d. Increase the IV infusion rate
What is "C", assess for bladder distension
300
Prior to the blood transfusion, the nurse reecords Marie’s vital signs to be: T 97.8, BP 78/50, pulse 110, respirations 22. Fifteen minutes after the transfusion is begun, another set of vital signs is taken: T 98.5, BP 76/48, pulse 112 and respirations 22. Marie complains of being cold. 16. What should the nurse do in response to these assessment findings? a. Decrease the rate of the transfusion to 50mL/hr b. stop the transfusion and call the health care provider c. Provide a warm blanket and continue to monitor d. Compare the blood type on the blood labels with the requisition forms
What is "C" provide a warm blanket and continue to monitor
300
20. Who is the best person to speak with Marie’s health care provider? a. The unit clerk who answered the call b. Marie’s nurse who has already given the shift report and is preparing to clock out c. The charge nurse who is leaving, but is sitting at the desk finishing up some last-minute paperwork d. Marie’s new nurse who is still receiving the in shift report
What is "B" Marie’s nurse who has already given the shift report and is preparing to clock out
300
18. Considering Marie’s history, what would be the most likely cause of Marie’s headache? a. Oxygen administration (3 liters/nasal cannula) b. Epidural anesthesia c. Straining during delivery d. Side effect of oxytocin
What is "B", epidural anesthesia
400
14. What should the nurse do to prepare for Marie's blood transfusion? Select all that apply. a. Reduce complications of rapid transfusion by using a blood warmer. b. Start an additional IV using a 16 or 18 gauge angiocath c. Prime a new Y-set blood tubing using a new bag of normal saline d. Monitor for fluid overload by assessing lab results, urine output, and respiratory status e. Explain the blood transfusion process to Marie
What is "B", "C", "E" b. Start an additional IV using a 16 or 18 gauge angiocath c. Prime a new Y-set blood tubing using a new bag of normal saline e. Explain the blood transfusion process to Marie
400
While Marie is resting, the blood bank calls and tells the nurse that Marie's infant blood type is A postive, and the blood drawn from Marie after delivery indicates that she is indirect Coomb's negative and non-sensitized. 23. Based on this information, what is the correct nursing action? a. Obtain RhoGam from the blood bank, and administer it as soon as possible b. Allow Marie to rest during the blood transfusion, and administer the RhoGam as prescribed at a later time c. Notify the health care provider and request a Coomb's postive blood test for Marie and her infant
What is "B", allow Marie to rest during the blood transfusion, and administer the RhoGam as prescribed at a later time
400
Marie's Total Intake 2,435mL Marie's Total Output 2,200mL (600mL urine via catheterization prior to birth 4 hours ago) 17. The nurse is aware that while Marie’s condition is stabilizing, she is still at risk for further hemodynamic complications. What action should the nurse take next, based on the assessment data just obtained? a. Contact respiratory therapy to obtain a blood gas to verify the (SaO2) reading b. Restrict Marie’s oral fluid intake to balance intake and output c. Palpate Marie’s bladder for fullness and catheterize if indicated d. Request a prescription for hourly hemoglobin and hematocrit measurements
What is "C" palpate Marie’s bladder for fullness and catheterize if indicated
400
21. Which task is best for the nurse to delegate to the UAP? a. Go to the blood bank and pick up the second unit of A negative blood b. Provide peri-care so the nurse can insert the Foley catheter c. Obtain and document Marie’s vital signs d. Check on the status of Marie’s infant and assure Marie that he is receiving good care
What is "C", obtain and document Marie's vital signs
400
2. What is the priority nursing diagnosis for Marie, who is experiencing residual effects of epidural anesthesia? a. Risk for injury b. Impaired physical mobility c. Altered urinary elimination d. Risk for infection
What is "A" risk for injury
500
10. What is the flow rate needed to deliver 40mU/minute?
What is 240mL/hr 10,000mU=1,000mL 40mU/1 min x 60min/1 hr=240 mU/1hr 240mU/ x mL= 10,000mU/1,000mL 10,000 x=2,400,000/10,000 x=240mL/hr
500
Marie's husband comes to the nurses station and asks for an update on Marie's condition. The nurse explains that Marie is resting while recieving her second unit of blood, her fundus is firm, vital signs are stable, and that she was able to use the bedpan to void. She tells the husband that when Marie sat up to void, she developed a severe migraine and is now being treated for PDPH. The nurse explains this disorder and the necessary treatment. The husband becomes frustrated and stroms out of the unit shouting "I can't believe you incompetent people here at this hospital! First you almost let my wife bleed to death, and now I find out that the idiot who put in the epidural catheter didn't know what he was doing! Someone is going to pay for this!" Mr. Wilson goes into Marie's room where she is breastfeeding the baby. Ten minutes later, the Infant Abduction alarm on the unit is activated and the nurse sees Mr. Wilson walking out of the door with an infant in his arms. 24. What priority action should the nurse implement? a. Notify the security personnel and direct all staff to report to their assigned exit in the hospital b. Document the observation in the client record and submit an incident report to risk managment c. Notify the health care provider about the husbands reaction and behavior d. Request that pastoral care personnel locate the husband and discuss the issues.
What is "A", a. Notify the security personnel and direct all staff to report to their assigned exit in the hospital
500
Marie’s new nurse prepares to administer the caffeine and sodium benzoate 0.5g IV. She introduces herself to Marie and explains the reason that she is experiencing severe migraines when she gets out of bed is because she has a postdura puncture headache (PDPH) that sometimes occurs after epidural anesthesia. The nurse explains that the headache and associated symptoms usually last 3 to 5 days. 22. What further teaching would be most important for the nurse to include at this time? a. Indications and mechanism of action of caffeine sodium benzoate b. Reason for the Foley catheter until the headaches resolves c. PDPH is usually accompanied by nausea, and Zofran is available as needed d. Strict, reclined bed rest and severe headaches may limit breastfeeding ability
What is "A", indications and mechanism of action of caffeine sodium benzoate
500
6. What is the best method for the nurse to use to obtain immediate assistance? a. Telephone the health care provider from the client’s room b. Go to the nurse’s station to notify the charge nurse c. Activate the priority call light from the bedside d. Call for help from the doorway of the client’s room
What is "C", activate the priority call light from the bedside
500
What is the course ID for this class? a. 0302-476-006 b. 0302-476-007 c. 0302-476-008 d. 0302-476-009
What is "C", 0302-476-008
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