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A 10-month-old girl is admitted with a diagnosis of possible cystic fibrosis. What question should the nurse ask the parent to assist in the diagnosis of cystic fibrosis (CF)?
- A. When you kiss her, does she taste salty?
- B. Do you notice if her urine has a musty odor?
- C. Has she been drinking cow's milk in her daily diet?
- D. How often does she have a normal bowel movement?
Correct Answer: A
Rationale: The correct answer is A. Salty skin is a common sign of cystic fibrosis due to high levels of sodium in sweat. Asking about the taste of the child's skin provides valuable information related to the diagnosis of CF. Choices B, C, and D are not helpful in diagnosing cystic fibrosis. A musty odor in urine is not a typical symptom of CF. Drinking cow's milk or bowel movement frequency are not specific to CF diagnosis.
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The nurse assesses a client one hour after starting a transfusion of packed red blood cells and determines that there are no indications of a transfusion reaction. What instructions should the nurse provide the unlicensed assistive personnel (UAP) who is working with the nurse?
- A. Continue to measure the client's vital signs every thirty minutes until the transfusion is complete
- B. Since a reaction did not occur, the priority is to maintain client comfort during the transfusion
- C. Monitor the client carefully for the next three hours and report the onset of a reaction immediately
- D. Notify the nurse when the transfusion has finished, so further client assessment can be done
Correct Answer: A
Rationale: The correct instruction for the UAP is to continue measuring the client's vital signs every thirty minutes until the transfusion is complete. This is important because continuous monitoring of vital signs during the transfusion helps detect any delayed reactions promptly. Choice B is incorrect because maintaining client comfort is important but not the priority over monitoring vital signs. Choice C is incorrect as monitoring should be ongoing and not limited to a specific time frame. Choice D is incorrect as the UAP should monitor vital signs throughout the transfusion, not just at the end.
The nurse is caring for a group of clients on a surgical unit. Which client should the nurse assess first?
- A. A client who is two days post knee surgery and describes pain at a "4" on a 1 to 10 scale
- B. A client who is one day post bowel resection with no bowel sounds
- C. A client who is 8 hours post appendectomy with urinary output of 480 ml
- D. A client who was admitted with severe abdominal pain and suddenly has no pain
Correct Answer: D
Rationale: The correct answer is D. A sudden absence of pain in a client with severe abdominal pain may indicate a serious condition such as internal bleeding. This sudden change in pain status requires immediate assessment to rule out any life-threatening complications. Choices A, B, and C do not indicate an acute change in the client's condition that would necessitate immediate attention compared to sudden pain relief in a client with severe abdominal pain.
Four clients arrive on the labor and delivery unit at the same time. Which client should the nurse assess first?
- A. A 38-week primigravida who reports contractions occurring every 10 minutes
- B. A 39-week primigravida with a biophysical profile score of 5 out of 8
- C. A 41-week multigravida who is scheduled for induction of labor today
- D. A 36-week multigravida with a prescription for serial blood pressure
Correct Answer: B
Rationale: The correct answer is B. A biophysical profile score of 5 out of 8 indicates potential fetal distress, necessitating immediate assessment to ensure the well-being of the fetus. The other options, while important, do not suggest an immediate threat to the fetus' health. The 38-week primigravida with contractions every 10 minutes may be in early labor, the 41-week multigravida scheduled for induction can be assessed after addressing the immediate concern, and the 36-week multigravida with serial blood pressure can be assessed after ensuring the client with potential fetal distress is stabilized.
While eating at a restaurant, a gravid woman begins to choke and is unable to speak. What action should the nurse who witnesses the event take?
- A. Cardiopulmonary resuscitation with uterine tilt
- B. The Heimlich maneuver using chest thrusts
- C. The Heimlich maneuver using subdiaphragmatic thrusts
- D. Call 911 immediately then begin cardiopulmonary resuscitation
Correct Answer: C
Rationale: The correct action for the nurse to take when a pregnant woman is choking and unable to speak is to perform the Heimlich maneuver using subdiaphragmatic thrusts. This technique is recommended for a pregnant woman to prevent harm to the fetus. Option A, cardiopulmonary resuscitation with uterine tilt, is not indicated for a choking episode. Option B, the Heimlich maneuver using chest thrusts, can potentially harm the gravid uterus. Option D, calling 911 immediately before providing assistance, can lead to a delay in addressing the immediate choking emergency.
The nurse is managing the care of a client with Cushing's syndrome. Which interventions should the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply)
- A. Evaluate the client for sleep disturbances
- B. limit client exercise
- C. Report any client complaint of pain or discomfort
- D. Note and report the client's food and liquid intake during meals and snacks
Correct Answer: D
Rationale: Weighing the client and monitoring food and liquid intake are appropriate tasks to delegate to the unlicensed assistive personnel (UAP) when managing a client with Cushing's syndrome. These tasks provide essential information for evaluating the client's condition and response to treatment. Evaluating for sleep disturbances and reporting client complaints of pain or discomfort require a higher level of assessment and interpretation, which should be performed by licensed healthcare providers. Therefore, options A and C are tasks that involve assessment and interpretation beyond the scope of practice for UAP.