Nokea
A client is admitted to the labor and delivery unit in early labor, and the nurse assesses the status of her contractions. The frequency of contractions is most accurately evaluated by counting the minutes and seconds in which manner?
- A. From the peak of one contraction to the peak of the next contraction
- B. From the beginning of one contraction to the end of that contraction
- C. From the beginning of one contraction to the beginning of the next contraction
- D. From the end of one contraction to the beginning of the next contraction
Correct Answer: C
Rationale: The frequency of contractions is measured from the beginning of one contraction to the beginning of the next contraction. This timing is crucial in determining the progress of labor. Choice A, measuring from peak to peak, is incorrect as it assesses the duration between the highest points of contractions, which is not how frequency is calculated. Choice B, measuring from the beginning to the end of one contraction, is incorrect as it does not consider the start of the next contraction. Choice D, measuring from the end of one contraction to the beginning of the next contraction, is incorrect as it misses the initial onset of the following contraction.
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When preparing to discharge a male client who has been hospitalized for an adrenal crisis, the client expresses concern about having another crisis. He tells the nurse that he wants to stay in the hospital a few more days. Which intervention should the nurse implement?
- A. Administer antianxiety medication before providing discharge instructions
- B. Schedule a follow-up appointment for an outpatient psychosocial assessment
- C. Obtain a blood cortisol level before discharge
- D. Encourage the client to remain in the hospital for a few more days
Correct Answer: B
Rationale: The correct intervention is to schedule a follow-up appointment for an outpatient psychosocial assessment. This option addresses the client's concerns and provides support for managing stress and preventing future crises, which is crucial for the client's long-term care. Administering antianxiety medication before providing discharge instructions (Choice A) may not effectively address the underlying concerns. Obtaining a blood cortisol level before discharge (Choice C) is important but not the priority in this situation. Encouraging the client to remain in the hospital for a few more days (Choice D) is not the best course of action as it may not address the client's anxiety and could potentially lead to other issues.
After administering a proton pump inhibitor (PPI), which action should the nurse take to evaluate the effectiveness of the medication?
- A. Ask the client about gastrointestinal pain
- B. Measure the client's fluid intake and output
- C. Monitor the client's serum electrolyte levels
- D. Auscultate for bowel sounds in all quadrants
Correct Answer: A
Rationale: The correct answer is A: Ask the client about gastrointestinal pain. The effectiveness of a proton pump inhibitor (PPI) is best evaluated by assessing the relief of gastrointestinal symptoms, such as heartburn, acid reflux, or stomach pain. These medications work by reducing the production of stomach acid, so improvement in these symptoms indicates the effectiveness of the PPI. Choices B, C, and D are incorrect because they do not directly reflect the effectiveness of a PPI. Measuring fluid intake and output, monitoring serum electrolyte levels, and auscultating for bowel sounds are important for assessing hydration status, electrolyte balance, and gastrointestinal motility, respectively. However, they are not specific to evaluating PPI effectiveness.
An adult male was diagnosed with stage IV lung cancer three weeks ago. His wife approaches the nurse and asks how she will know that her husband's death is imminent because their two adult children want to be there when he dies. What is the best response by the nurse?
- A. Explain that the client will start to lose consciousness and his body systems will slow down
- B. Reassure the spouse that the healthcare provider will let her know when to call the children
- C. Offer to discuss the client's health status with each of the adult children
- D. Gather information on how long it will take for the children to arrive
Correct Answer: A
Rationale: The best response for the nurse is to explain that the client will start to lose consciousness and his body systems will slow down. Providing information on the signs of impending death helps the family prepare emotionally and allows them to be present at the appropriate time. Choice B is incorrect because it does not empower the family with the knowledge they seek. Choice C is incorrect as discussing the client's health status individually with the adult children may not address the wife's immediate concern. Choice D is incorrect as the priority should be on preparing the family for the signs of imminent death rather than focusing on logistical details.
A client with a peripherally inserted central catheter (PICC) line has a fever. What client assessment is most important for the nurse to perform?
- A. Observe the PICC line site for inflammation.
- B. Encourage increasing fluid intake.
- C. Monitor blood pressure regularly.
- D. Assess skin turgor for dehydration.
Correct Answer: A
Rationale: The correct answer is to observe the PICC line site for inflammation. When a client with a PICC line develops a fever, it could indicate an infection related to the catheter. Assessing the PICC line site for signs of inflammation, such as redness, warmth, swelling, or drainage, is crucial in identifying a potential infection early. Choice B is incorrect because increasing fluid intake is not directly related to assessing a PICC line for infection. Choice C is not the most appropriate assessment in this situation as monitoring blood pressure may not directly help in identifying the cause of the fever. Choice D is unrelated to the assessment of a fever in a client with a PICC line.
Before administering an intramuscular injection, the nurse's finger is stuck with the needle. Which action should the nurse take?
- A. Go to the emergency room to have blood drawn
- B. Prepare the medication using a new syringe
- C. Apply clean gloves before giving the medication
- D. Review the medical history in the client's chart
Correct Answer: B
Rationale: In this scenario, if the nurse's finger is stuck with the needle before administering the injection, the correct action is to prepare the medication using a new syringe. This step is crucial to prevent contamination and ensure the safety of the patient. Going to the emergency room to have blood drawn is unnecessary and does not address the immediate issue of contamination. Applying clean gloves is important for infection control but does not address the potential contamination from the needlestick. Reviewing the medical history in the client's chart is important for overall patient care but is not the priority in this situation where immediate action is required to prevent harm.