Nokea
A client in the second stage of labor has had no anesthesia or analgesia. The nurse should assist the client into which of the following positions so the client can begin pushing?
- A. Squatting with the body curved in a C shape.
- B. Side-lying while keeping the head elevated.
- C. In the knee-chest position while keeping the head lowered.
- D. Squatting with the back arched.
Correct Answer: A
Rationale: Squatting with a C-shaped body facilitates pushing by aligning the pelvis and using gravity, ideal for the second stage of labor without anesthesia.
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A client with acute stress disorder is telling the nurse about the tornado that leveled his house and killed his wife and baby while he was out of town on business. He states, 'If only I'd been at home, I could have saved them.' Which of the following responses would be most appropriate?
- A. Don't blame yourself; you'll only feel worse.'
- B. It's not your fault; so stop feeling so guilty.'
- C. You might not have been at home.'
- D. You couldn't have prevented the tornado; it just happened.'
Correct Answer: D
Rationale: Acknowledging the uncontrollable nature of the tornado helps the client process guilt rationally, supporting coping with acute stress disorder.
A client has undergone a vaginal hysterectomy. Which interventions should the nurse include in the client's nursing care plan to decrease the risk of deep vein thrombosis or thrombophlebitis? Select all that apply.
- A. Use pneumatic compression boots.
- B. Maintain bed rest for 24 to 48 hours.
- C. Assist with range-of-motion leg exercises.
- D. Elevate the knees with the knee gatch on the bed.
- E. Remove antiembolism stockings twice daily for assessment.
Correct Answer: A,C,E
Rationale: The client is at risk for deep vein thrombosis or thrombophlebitis after this surgery, as for any other major surgery. For this reason, the nurse implements measures that will prevent this complication. Ambulation, pneumatic compression boots, range-of-motion exercises, and antiembolism stockings are all helpful. The nurse should avoid elevating the knees using the knee gatch in the bed, which inhibits venous return and places the client more at risk for deep vein thrombosis or thrombophlebitis.
A client is diagnosed with pernicious anemia. The nurse reviews the client's health history for disorders involving which organ responsible for vitamin B12 absorption?
- A. Liver
- B. Ileum
- C. Kidney
- D. Hepatobiliary
Correct Answer: B
Rationale: Pernicious anemia can occur in a client who has a disease involving the ileum, where vitamin B12 is absorbed. The nurse checks the client's history for small bowel disorders to detect this risk factor. The liver and the kidney are not related to impaired B12 absorption. Hepatobiliary refers to the liver and gallbladder.
The nurse is preparing to insert a urinary catheter. Which action ensures sterile technique?
- A. Cleanse the meatus with an alcohol swab
- B. Use clean gloves during insertion
- C. Apply sterile lubricant to the catheter tip
- D. Insert the catheter without a drape
Correct Answer: C
Rationale: Applying sterile lubricant to the catheter tip maintains sterile technique, reducing the risk of infection during urinary catheter insertion.
A client with a history of stroke is at risk for aspiration. Which of the following interventions should the nurse include in the plan of care? Select all that apply.
- A. Position the client upright during meals.
- B. Offer thin liquids to promote swallowing.
- C. Assess the client's gag reflex before feeding.
- D. Provide small, frequent meals.
- E. Thicken liquids as needed.
Correct Answer: A, C, D, E
Rationale: Upright positioning, assessing gag reflex, small frequent meals, and thickened liquids reduce aspiration risk. Thin liquids increase risk.