When planning care for a client whose membranes have ruptured, the nurse recognizes that the client's risk is increased for
a. cervical lacerations c. precipitous labor
b. intrauterine infection d. supine hypotension
B
The longer the membranes have been ruptured, the greater the risk of infection. Pushing before the start of the second stage of labor can result in cervical tears. Precipitous delivery means the delivery occurs before the primary care provider arrives. Supine hypotension occurs because of positioning and is not related to the rupture of the membranes.
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The nurse is preparing to insert a peripheral IV catheter into a patient who will require fluids and IV antibiotics. How should the nurse always start the process of insertion?
A) Leave one hand ungloved to assess the site. B) Cleanse the skin with normal saline. C) Ask the patient about allergies to latex or iodine. D) Remove excessive hair from the selected site.
A patient underwent a thoracotomy 12 hours ago. The patient currently has an epidural catheter in place and is receiving continuous epidural analgesia with morphine
In addition to respiratory depression, the patient should be monitored for which of the following complications? a. Urinary retention, undue somnolence, itching, nausea, and vomiting b. Urinary incontinence, photophobia, headache, and skin rash c. Apprehension, anxiety, restlessness, sadness, anger, and myoclonus d. Gastric bleeding, nasal discharge, cerebrospinal fluid leak, and calf pain
A client scheduled for a stress echocardiogram is to receive an IV infusion of Dextrose 5% in Water (D5W) with dobutamine (Dobutrex) 0.5 grams/250 ml at a rate of 1,200 mcg/minute. The nurse should program the infusion pump to deliver how many ml/hour?
A. 160 ml/hr B. 225 ml/hr C. 26 ml/hr D. 36 ml/hr
A nurse works with a patient to establish outcomes. The nurse believes that one outcome suggested by the patient is not in the patient's best interest. What is the nurse's best action?
a. Remain silent. b. Educate the patient that the outcome is not realistic. c. Explore with the patient possible consequences of the outcome. d. Formulate an appropriate outcome without the patient's input.