Nokea
A 28-year-old woman pregnant with twins comes in for her prenatal appointment. She tells the nurse that she has two children at home (ages 4 years and 16 months), and she had one abortion 6 years ago when she was 8 weeks along in the pregnancy. The nurse charts
- A. gravida 4, para 2.
- B. gravida 4, para 3.
- C. gravida 5, para 2.
- D. gravida 5, para 3.
Correct Answer: C
Rationale: Gravida counts all pregnancies (2 children, 1 abortion, current twin pregnancy = 5). Para counts deliveries after 20 weeks (2 children = 2). Twins count as one delivery.
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A 25-year-old male is brought to the emergency room with a piece of metal in his eye. The first action the nurse should take is:
- A. Use a magnet to remove the object.
- B. Rinse the eye thoroughly with saline.
- C. Cover both eyes with paper cups.
- D. Patch the affected eye.
Correct Answer: C
Rationale: Covering both eyes prevents eye movement, reducing further damage.
An older man is seen in the outpatient clinic for treatment of an acute attack of gout. Which of the following nursing interventions would be MOST beneficial in decreasing the client’s pain during ambulation?
- A. Perform passive range-of-motion exercises before walking.
- B. Encourage partial weight bearing while ambulating.
- C. Immobilize the extremity between activities.
- D. Restrict the amount of time and the distance the man walks.
Correct Answer: B
Rationale: would relieve weight, pressure, and stress on affected leg, may use walker
The nurse is assigning staff for the day. Which client should be assigned to the nursing assistant?
- A. A 5-month-old with bronchiolitis
- B. A 10-year-old 2-day post-appendectomy
- C. A 2-year-old with periorbital cellulitis
- D. A 1-year-old with a fractured tibia
Correct Answer: B
Rationale: A stable post-appendectomy patient requires basic care, suitable for a nursing assistant.
A client with cancer who is receiving chemotherapeutic drugs has been given injections of (pegfilgastrin) Neulasta. Which laboratory value reveals that the drug is producing the desired effect?
- A. Hemoglobin of 13.5 g/dL
- B. White blood cells count of 6,000/mm
- C. Platelet count of 300,000/mm
- D. HCT 39%
Correct Answer: B
Rationale: Pegfilgrastim (Neulasta) stimulates white blood cell production. A WBC count of 6,000/mm indicates the drug is effective in preventing neutropenia.
The nurse is making initial rounds on a client with a C5 fracture. The client is in a halo vest and is receiving O2 at 40% via mask to a tracheostomy. Assessment reveals a respiratory rate of 40 and O2 saturation of 88. The client is restless. Which initial nursing action is most indicated?
- A. Notifying the physician
- B. Performing tracheal suctioning
- C. Repositioning the client to the left side
- D. Rechecking the client's O2 saturation
Correct Answer: B
Rationale: Restlessness, tachypnea, and low O2 saturation suggest airway obstruction or secretions. Tracheal suctioning is the initial action to clear the airway and improve oxygenation.