1. turn the mother on her right side, increase the intravenous flow rate, and call the physician.
2. turn the mother on her left side, administer oxygen by nasal cannula, and start an IV.
3. call the physician, and make preparations for an immediate emergency cesarean section.
4. position the mother in Trendelenburg’s position, administer oxygen, and force fluids.
Strategy: “FIRST” indicates that this is a priority question. All answers are implementations. Determine the outcome of each answer choice. Is it desired?
(1) should be placed on left side to increase blood flow to the uterus
(2) correct—persistent fetal bradycardia may indicate cord compression or separation of the placenta, but always indicates fetal distress, left side reduces compression of vena cava and aorta
(3) should be done after positioning patient
(4) this position is used
1020. After a client has returned to the floor from thyroidectomy surgery, it is MOST important for the nurse to take which of the following actions?
1. Monitor vital signs every four hours.
2. Observe for frequent swallowing.
3. Monitor for signs of respiratory distress every hour.
4. Position the client in the supine position.
Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Determine what assessment is being made in each answer choice.
(1) assessment is not specific to this surgery
(2) assessment, method used to monitor for postoperative hemorrhage in a tonsillectomy client
(3) correct—assessment, after surgery, swelling can occur, which causes respiratory distress
(4) implementation, head of the bed should be elevated
1021. The nurse is caring for clients on the psychiatric unit. Suddenly, a male client’s behavior begins to escalate into aggressive behavior. It would be MOST important for the nurse to take which of the following actions?
1. Utilize an organized team to place the client in seclusion.
2. Leave the client alone in his room to identify feelings of anger.
3. Redirect the client to a quiet activity to divert his attention and not disturb the other clients.
4. Assist the client to identify and express his feelings of increasing anxiety, frustration, and anger.
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?
(1) nurse can be helpful in using psychological/communication strategies before utilizing seclusion
(2) leaving the client alone can become potentially dangerous to the client and the property
(3) encouraging the client to become involved in a quiet activity might further escalate his frustration and anger because the ability to focus and concentrate is diminished due to an elevated anxiety level
(4) correct—as client’s anger begins to escalate, nurse can be helpful in using psychological/communication strategies before utilizing seclusion only if there is cord prolapsed