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A client in labor has an electronic fetal monitor attached to the abdomen, and the nurse notes that the baby's heart rate slows down during each contraction, returning to normal limits only after the contraction is complete. Which type of fetal heart rate change does this pattern describe?
- A. Variable decelerations
- B. Late decelerations
- C. Early decelerations
- D. Accelerations
Correct Answer: B
Rationale: Late decelerations refer to a pattern where the baby's heart rate decreases during contractions and does not return to normal until after the contraction ends. This is considered a non-reassuring sign as it indicates potential fetal distress. Late decelerations are associated with uteroplacental insufficiency, and immediate medical attention is required. Variable decelerations (Choice A) are abrupt, unpredictable decreases in the fetal heart rate, usually associated with cord compression. Early decelerations (Choice C) are usually benign and mirror the contraction pattern. Accelerations (Choice D) are reassuring signs of fetal well-being, characterized by an increase in the fetal heart rate.
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A client has started sweating profusely due to intense heat. His overall luid volume is low and he has developed electrolyte imbalance. This client is most likely suffering from:
- A. Malignant hyperthermia
- B. Heat exhaustion
- C. Heat stroke
- D. Heat cramps
Correct Answer: B
Rationale: Heat exhaustion occurs when a person has enough diaphoresis that he becomes dehydrated. Intense sweating can cause both luid and electrolyte imbalances. Untreated heat exhaustion canlead to heat stroke, which results in organ damage, loss of consciousness, or death.
A client diagnosed with anxiety disorder is prescribed buspirone orally. When the client reports that it is difficult to swallow the tablets, the nurse provides which instruction to promote compliance?
- A. Crush the tablets before taking them.
- B. Mix the tablet uncrushed in applesauce.
- C. Purchase the liquid preparation with the next refill.
- D. Call the primary health care provider for a change in medication.
Correct Answer: A
Rationale: Buspirone tablets may be crushed and administered without regard to meals, making this the most effective instruction to promote compliance for a client who finds swallowing difficult. Mixing the tablet uncrushed in applesauce does not address the swallowing issue. Buspirone is not available in liquid form, and calling the primary health care provider for a medication change is premature before trying this intervention.
Percussion is a physical assessment technique that is used to identify which findings?
- A. Fluid in body cavities
- B. Borders of body organs
- C. Consistency of body organs
- D. Mobility of organs and other structures
- E. Resilience and resistance of tissue and organs
- F. Location, size, and density of an underlying structure
Correct Answer: A,B,C,F
Rationale: Percussion involves tapping the body with the fingertips to evaluate the size, borders, and consistency of body organs and assess for fluid in body cavities. Through percussion, the location, size, and density of an underlying structure can be determined. Through palpation, assessment is done via the sense of touch. Measurements of specific physical signs, including resistance, resilience, roughness, texture, and mobility, can be made through palpation.
The nurse provides home care instructions to a client diagnosed with cancer who has an implanted vascular access port. Which statement by the client indicates the need for further teaching?
- A. I should keep the site clean and dry.
- B. If the site becomes red, I will notify my doctor.
- C. I should pump the port daily to maintain patency.
- D. The port will need to be flushed with saline to maintain patency.
Correct Answer: C
Rationale: Implanted vascular access ports do not require daily pumping to maintain patency; this is incorrect. Keeping the site clean and dry, notifying the doctor about redness, and flushing with saline (or heparin, per agency protocol) are correct care measures.
Clonazepam has been prescribed for the client, and the nurse teaches the client about the medication. Which statement by the client indicates that further teaching is necessary?
- A. If I experience slurred speech, it will disappear in about 8 weeks.
- B. My drowsiness will decrease over time with continued treatment.
- C. I should take my medicine with food to decrease stomach problems.
- D. I can take my medicine at bedtime if it tends to make me feel drowsy.
Correct Answer: A
Rationale: Clonazepam is a benzodiazepine. Clients who experience signs/symptoms of toxicity with the administration of clonazepam exhibit slurred speech, sedation, confusion, respiratory depression, hypotension, and eventually coma. Some drowsiness may occur, but it will decrease with continued use. The medication may be taken with food to decrease gastrointestinal irritation. The medication may be taken at bedtime if drowsiness does occur. Slurred speech indicates toxicity and should be reported immediately, not expected to disappear in 8 weeks.