Mrs. Jimenez is a 28-year-old pregnant woman who is in labor. Due to the fact that her labor was progressing very slowly, she was started on an infusion of oxytocin, a drug used to increase the progression of her labor
In the planning of Mrs. Jimenez's care, the nurse has
documented a "Risk of Fluid Volume Excess" in light of this common adverse effect of oxytocin. The nurse has demonstrated the use of what nursing classification system?
A) The Minimum Data Set (MDS)
B) Nursing Outcomes Classification (NOC)
C) Nursing Interventions Classification (NIC)
D) NANDA International (NANDA-I)
Ans: D
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As the nurse is coming on duty to take over the day shift, the night nurse tells the nurse that she has already counted the controlled drugs for the day shift. What should the nurse do in this situation?
a. Do nothing; this is standard procedure. b. Accept the keys and recount the drugs. c. Recount the drugs with another nurse. d. Count the drugs at the end of your shift.
When caring for the patient with type 1 diabetes, the nurse includes which of the following in the plan of care?
1. Administer insulin lispro or aspart immediately prior to the meal. 2. Administer oral hypoglycemic medications ½ hour prior to meals. 3. Observe for hypoglycemia approximately ½ to 1 hour after injecting NPH insulin. 4. Avoid insulin if the patient reports an allergy to sulfa drugs.
A patient receiving haloperidol urgently calls to the nurse and reports that his eyes have rolled upward and he cannot redirect his gaze. The nurse contacts the physician to seek an order for:
a. Fluphenazine (Prolixin) b. Citalopram (Celexa) c. Benztropine (Cogentin) d. Risperidone (Risperdal)
All patients undergoing surgery need to have preoperative preparation. When physically preparing the patient, the most appropriate action for the nurse to take is:
A. leaving all of the patient's jewelry in place. B. removing the patient's makeup and nail polish. C. providing the patient with sips of water for a dry mouth. D. removing the patient's hearing aid before transport to the operating room.