Nokea
A client is admitted to the labor and delivery unit in active labor. During examination, the nurse notes a papular lesion on the perineum. Which initial action is most appropriate?
- A. Document the finding
- B. Report the finding to the doctor
- C. Prepare the client for a C-section
- D. Continue primary care as prescribed
Correct Answer: B
Rationale: A papular lesion on the perineum during labor could indicate an infectious process (e.g., herpes), so reporting it to the doctor is the most appropriate initial action.
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A client's serum sodium level is 113 mEq/L. The nurse would expect which findings upon assessment?
- A. headache, confusion, muscle weakness, fatigue
- B. hypertension, muscle cramps, respiratory depression
- C. cardiac arrhythmia, tetany, tachycardia
- D. confusion, nystagmus, tetany, hallucinations
Correct Answer: A
Rationale: Severe hyponatremia (113 mEq/L) causes neurological symptoms like headache, confusion, muscle weakness, and fatigue due to cerebral edema.
A client with AIDS has impaired nutrition because of diarrhea. Which diet selection by the client would indicate a need for further teaching of foods that can worsen the diarrhea?
- A. Tossed salad
- B. Baked chicken
- C. Broiled fish
- D. Steamed rice
Correct Answer: A
Rationale: Raw vegetables in a tossed salad can exacerbate diarrhea in AIDS patients. Baked chicken, broiled fish, and steamed rice are easier to digest and less likely to worsen diarrhea.
A client in cardiac arrest is given 40 units of vasopressin (Pitressin) IV push. The nurse knows the desired action of this medication in a cardiac arrest is to
- A. raise blood pressure.
- B. stop cardiac arrhythmia.
- C. lower blood pressure.
- D. reset the electrical cardiac conduction system.
Correct Answer: A
Rationale: Vasopressin, used in cardiac arrest, is a vasopressor that raises blood pressure by vasoconstriction, improving perfusion during CPR.
An elderly client's wife tells a nurse she is concerned because her husband insists on talking about past events. The nurse assesses the client and finds him alert, oriented, and responsive to questions. Which statement should the nurse make to the client's wife?
- A. Your husband is choosing to live in a happier time in his life.
- B. Redirect your husband to speak about current events when he begins regressing into the past.
- C. If he were my husband, I would call our minister to speak to him.
- D. Your husband is reflecting on his life. This is normal at his age.
Correct Answer: D
Rationale: Reflecting on past events is a normal part of aging, especially in older adults, and this response reassures the wife while providing accurate information.
The nurse is caring for an obstetrical client in early labor. After the rupture of membranes, the nurse should give priority to:
- A. Applying an internal monitor
- B. Assessing fetal heart tones
- C. Assisting with epidural anesthesia
- D. Inserting a Foley catheter
Correct Answer: B
Rationale: Assessing fetal heart tones is critical after rupture of membranes to detect fetal distress, such as cord compression.