Nokea
The client asks the nurse how the health care provider could tell she was pregnant 'just by looking inside.' What is the best explanation by the nurse?
- A. Bluish coloration of the cervix and vaginal walls
- B. Pronounced softening of the cervix
- C. Clot of very thick mucous that obstructs the cervical canal
- D. Slight rotation of the uterus to the right
Correct Answer: A
Rationale: Chadwick's sign is a bluish-purple coloration of the cervix and vaginal walls, occurring at 4 weeks of pregnancy, that is caused by vasocongestion.
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It is MOST important for the nurse to take which of the following actions?
- A. Perform a straight catheterization.
- B. Offer the client the bedpan.
- C. Put the baby to breast.
- D. Massage the uterine fundus.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) encourage the client to void before catheterizing (2) correct-boggy uterus deviated to right indicates full bladder, encourage client to void (3) will increase uterine tone, but the problem is a full bladder (4) findings indicate a full bladder
The nurse is caring for an adult who has kidney stones. Which action is essential for the nurse to take?
- A. Take blood pressure frequently
- B. Keep the client on bed rest
- C. Position the client supine
- D. Strain all urine
Correct Answer: D
Rationale: Straining urine captures kidney stones for analysis, guiding treatment. Blood pressure, bed rest, or positioning are not primary.
A child is admitted in sickle cell crisis. Which factor in the child's history is most likely related to the onset of the crisis?
- A. The child just completed final exams at school.
- B. The child ran a marathon yesterday.
- C. The child recently had a cold.
- D. The child received a hepatitis A immunization two weeks ago.
Correct Answer: C
Rationale: Infections, like a recent cold, can trigger sickle cell crisis by increasing oxygen demand and causing dehydration, leading to sickling of red blood cells.
The nurse should
- A. elevate the patient's left thigh on two pillows.
- B. elevate the foot of the bed on blocks.
- C. raise the knee gatch on the bed 30°.
- D. instruct the patient to remain in the middle of the bed.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) will not prevent patient from sliding down; may change pull of traction (2) correct-will keep leg straight and counter the pull of the weights (3) will bend the leg and alter the pull of the traction (4) not effective way of preventing the patient from sliding down in bed
A 16-year-old client is admitted for elective surgery. The LPN is asked to have the child's mother sign the operative permit. Which action by the nurse is most appropriate?
- A. Have the parent sign the permit form
- B. Refuse to ask the parent to sign the permit form
- C. Ask the unit secretary to have the parent sign the permit form
- D. Have both the child and the parent sign the permit form
Correct Answer: A
Rationale: For minors, a parent or guardian must sign the operative permit, as they provide legal consent for the procedure.