Nokea
The nurse observes a woman in the first stage of labor and encourages her to push before the cervix is fully dilated. The nurse's action could primarily lead to
- A. Call the health care provider
- B. Encourage deep breathing
- C. Elevate the foot of the bed
- D. Turn her to her left side
Correct Answer: D
Rationale: The weight of the uterus can put pressure on the vena cava and aorta when a pregnant woman is flat on her back causing supine hypotension. Turning the woman to the side reduces this pressure and relieves postural hypotension.
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While assessing a client with AIDS, the nurse notes a reddish-purple discoloration on the client's eyelid. This finding is most consistent with:
- A. Cytomegalovirus retinitis
- B. AIDS entropion
- C. Retinitis pigmentosa
- D. Kaposi's sarcoma
Correct Answer: D
Rationale: Kaposi's sarcoma, common in AIDS, presents as reddish-purple lesions, including on the eyelid. Other conditions affect the retina or eyelid structure differently.
When teaching how to use nitroglycerin, the nurse tells the client to place 1 tablet under the tongue when pain occurs and to repeat the dose in 5 minutes if pain persists. The nurse should also tell the client to
- A. place 2 tablets under the tongue when intense pain occurs.
- B. swallow 1 tablet and place under the tongue when pain is intense.
- C. place 1 tablet under the tongue 3 minutes before activity and repeat the dose in 5 minutes if pain occurs.
- D. place 1 tablet under the tongue when pain occurs and use an additional tablet after the attack to prevent recurrence.
Correct Answer: D
Rationale: Anginal pain, which can be anticipated during certain activities, may be prevented by dilating the coronary arteries immediately before engaging in activity, and an additional tablet post-attack can prevent recurrence.
In Cushing's syndrome excessive amounts of glucocorticoids and mineralcorticoids will increase the patient's:
- A. Urine output
- B. Glucose level
- C. Serum potassium
- D. Immune response
Correct Answer: B
Rationale: Excess glucocorticoids elevate glucose by promoting gluconeogenesis.
The nurse understands that a liver biopsy may be contraindicated in certain situations. Therefore, it is important for the nurse to assess the patient for:
- A. confusion and disorientation
- B. the presence of any infectious disease
- C. a prothrombin time of less than 40% of normal
- D. foods high in Vit K eaten before the biopsy
Correct Answer: C
Rationale: Prolonged prothrombin time indicates bleeding risk, a contraindication for liver biopsy.
Before the procedure, the nurse should instruct the patient to:
- A. Empty the bladder
- B. Eat foods low in fat
- C. Remain NPO for 24 hours
- D. Assume the supine position
Correct Answer: A
Rationale: Emptying the bladder prevents injury during paracentesis needle insertion.