Nokea
A client in the prenatal clinic is assessed to have a blood pressure of 180/96. The nurse should give priority to:
- A. Providing a calm environment
- B. Obtaining a diet history
- C. Administering an analgesic
- D. Assessing fetal heart tones
Correct Answer: D
Rationale: Severe hypertension (180/96) poses a risk to fetal well-being, prioritizing fetal heart tone assessment.
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A nurse needs to draw a blood sample from a patient's central line. The line is currently infusing Ringer's lactate. In which order should the nurse take the following steps to draw the blood sample? Number the steps below.
- A. attach the flush syringe and flush catheter with normal saline
- B. stop the infusion and disconnect Ringer's lactate
- C. withdraw a blood sample and discard
- D. scrub the catheter hub
- E. withdraw the blood sample for the lab
Correct Answer: B,D,C,A,E
Rationale: Order: Stop infusion (B), scrub hub (D), withdraw/discard blood (C), flush with saline (A), withdraw lab sample (E). This ensures a clean, accurate sample.
A client with epilepsy is taking phenytoin. What long-term effects should the nurse advise the client can occur with prolonged administration of phenytoin? Select all that apply.
- A. Gingival hypertrophy
- B. Hirsutism
- C. Hypertrophy of facial subcutaneous tissue
- D. Dementia
- E. Anemia
Correct Answer: A,B,E
Rationale: Phenytoin's long-term effects include gingival hypertrophy (A), hirsutism (B), and anemia (E). Facial hypertrophy (C) and dementia (D) are not associated with phenytoin.
Which of the following actions does NOT require the use of standard precautions?
- A. contact with blood
- B. contact with urine
- C. contact with sweat
- D. contact with vomit
Correct Answer: C
Rationale: Standard precautions are required for contact with blood, urine, and vomit due to potential infectious agents. Sweat is not considered a significant risk for transmission.
A 65-year-old client who recently retired from many years of working full-time for a company has become increasingly unmotivated and states he feels as though he has no purpose. Which of the following recommendations are most appropriate? Select all that apply.
- A. Volunteer or get a part-time job.
- B. Participate in community activities.
- C. Join a senior citizen's group.
- D. Be thankful he can afford to retire.
- E. Ask to have retirement reversed.
Correct Answer: A,B,C
Rationale: Volunteering/part-time work (A), community activities (B), and senior groups (C) provide purpose. Gratitude (D) is dismissive, and reversing retirement (E) is impractical.
A client is taking nebulizer treatments for asthma, and the nurse is instructing the client in the correct method for measuring peak expiratory flow rates (PEFR) after treatment. The nurse prepares the meter with the indicator at the base of the scale. Place the following steps (Roman numerals) in the correct order from first to last.
- A. Client sits upright or stands.
- B. Client places the meter in the mouth and seals lips.
- C. Client expels air through the meter as forcefully as possible.
- D. Client takes a deep breath.
Correct Answer: A,D,B,C
Rationale: PEFR sequence: Sit/stand (I), take deep breath (IV), place meter in mouth (II), expel air forcefully (III).