Nokea
The nurse assists with data collection during a routine prenatal visit for a client at 36 weeks gestation. Which statement by the client is most concerning to the nurse?
- A. I'm not sleeping as well due to cramps in my calves at night.
- B. I've noticed fewer kicking movements as the baby grows bigger.
- C. Over the last few weeks, I've been unable to wear any of my shoes.
- D. Sometimes I feel short of breath after walking up a flight of stairs.
Correct Answer: B
Rationale: Decreased fetal movement may indicate fetal distress and requires immediate evaluation.
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The nurse is preparing to flush a client's central venous catheter. Which size syringe is best for the nurse to choose?
- A. 1 mL
- B. 3 mL
- C. 10 mL
- D. 30 mL
Correct Answer: C
Rationale: A 10 mL syringe is recommended to avoid excessive pressure that could damage the catheter.
The nurse is caring for a newborn with jaundice who is being treated with phototherapy. What action by the nurse would require the charge nurse to intervene?
- A. Allowing the parents to feed the newborn
- B. Applying a shirt while the client is exposed to phototherapy
- C. Covering the client's eyes with protective shields
- D. Monitoring the temperature of the incubator while the newborn is inside
Correct Answer: B
Rationale: Clothing during phototherapy reduces skin exposure to light, decreasing treatment efficacy.
A nursing diagnosis of 'ineffective airway clearance related to pain' is identified for a client who had open abdominal surgery 2 days ago. Which intervention should the nurse implement first?
- A. Administer prescribed analgesic medication for incisional pain
- B. Encourage use of incentive spirometer every 2 hours while awake
- C. Offer an additional pillow to splint the incision while coughing
- D. Promote increased oral fluid intake
Correct Answer: A
Rationale: Pain control is the priority to enable effective coughing and airway clearance.
The nurse at an orthopedic joint clinic is assisting with the preparation of pre-operative teaching for clients scheduled for total hip replacement surgery. Which would be included in the teaching plan?
- A. Avoid sitting in a recliner
- B. Make sure that commode seats are at low levels
- C. Avoid crossing the legs when sitting
- D. Physical therapy will assist with adduction leg exercises
Correct Answer: C
Rationale: The client with joint hip replacement should avoid adduction of the legs and flexion of the hips greater than 90 degrees to ensure continued placement of the prosthetic joint. It is recommended for these clients to use recliners for seating instead of straight chairs, therefore A is incorrect. Commode seats will have to be raised and abduction of the legs is required, making B and D incorrect choices.
The nurse is conducting intake interviews at the clinic. Which client situations would require the nurse to intervene? Select all that apply.
- A. Client with iron deficiency anemia takes iron supplements with milk
- B. Client takes levothyroxine early in the morning on an empty stomach
- C. Client taking phenazopyridine for urine infection states that the urine has turned orange
- D. Client taking metronidazole mentions going to a wine-tasting party tonight
- E. Client with closed-angle glaucoma takes over-the-counter diphenhydramine for a cold
Correct Answer: A,D,E
Rationale: Milk reduces iron absorption, metronidazole with alcohol can cause severe reactions, and diphenhydramine can worsen closed-angle glaucoma.