Nokea
A client has received a dose of dimenhydrinate. The nurse determines that the medication is effective when the client obtains relief of which problem?
- A. Chills
- B. Headache
- C. Ringing in the ears
- D. Nausea and vomiting
Correct Answer: D
Rationale: Dimenhydrinate is used to treat and prevent the symptoms of dizziness, vertigo, and nausea and vomiting that accompany motion sickness. None of the other options are associated with the described symptoms.
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Which test result should the nurse review to determine the compatibility of blood from two different donors?
- A. Rh factor
- B. ABO typing
- C. Direct Coombs'
- D. Indirect Coombs'
Correct Answer: D
Rationale: The indirect Coombs' test detects circulating antibodies against red blood cells (RBCs) and is the screening component of a prescription to 'type and screen' a client's blood. This test is used in addition to the ABO typing, which is normally done to determine blood type. The Rh factor is determined at the same time as the ABO type. The direct Coombs' test is used to detect idiopathic hemolytic anemia by detecting the presence of autoantibodies against the client's RBCs.
Place the phases or stages of the inflammatory response in the correct sequential order, do NOT include any phases that is NOT part of the inflammatory process. 1. The vascular phase 2. The prodromal phase 3. The incubation phase 4. The initial injury 5. The exudate phase 6. The convalescence phase
- A. 4,2,1
- B. 4,1,5
- C. 4,5,1
- D. 4,2,5
Correct Answer: B
Rationale: The inflammatory response includes the initial injury (4), followed by the vascular phase (1, vasodilation and increased permeability), and then the exudate phase (5, fluid and cell migration). Prodromal (2), incubation (3), and convalescence (6) are not part of the inflammatory process. Thus, B (4,1,5) is correct.
A diabetic primigravid client at 38 weeks' gestation asks the nurse why she had a fetal acoustic stimulation during her last nonstress test. Which of the following should the nurse include as the rationale for this test?
- A. To listen to the fetal heart rate
- B. To startle and awaken the fetus
- C. To stimulate mild contractions
- D. To confirm amniotic fluid amount
Correct Answer: B
Rationale: Fetal acoustic stimulation is used to startle and awaken the fetus, prompting movement to assess fetal heart rate reactivity during a nonstress test. It does not directly measure heart rate, stimulate contractions, or assess amniotic fluid.
Which of the following goals is most important for a client with acute pancreatitis?
- A. The client reports minimal pain.
- B. The client regains a normal pattern for bowel movements.
- C. The client limits alcohol intake to two to three drinks per week.
- D. The client maintains normal liver function.
Correct Answer: A
Rationale: Minimizing pain is the most important goal in acute pancreatitis to improve client comfort and recovery.
The nurse judges that the parents of a newborn with imperforate anus know what a low defect is when they say that the rectum:
- A. Is below the abdominal rectus muscle
- B. Is above the abdominal rectus muscle
- C. Has descended through the puborectalis muscle
- D. Has ascended through the puborectalis muscle
Correct Answer: C
Rationale: A low defect in imperforate anus means the rectum has descended through the puborectalis muscle, indicating a less severe anomaly. Other options describe incorrect anatomical positions.