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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The nurse is caring for a group of clients on a surgical unit. Which client should the nurse assess first?
- A. A client who is two days post knee surgery and describes pain at a "4" on a 1 to 10 scale
- B. A client who is one day post bowel resection with no bowel sounds
- C. A client who is 8 hours post appendectomy with urinary output of 480 ml
- D. A client who was admitted with severe abdominal pain and suddenly has no pain
Correct Answer: D
Rationale: The correct answer is D. A sudden absence of pain in a client with severe abdominal pain may indicate a serious condition such as internal bleeding. This sudden change in pain status requires immediate assessment to rule out any life-threatening complications. Choices A, B, and C do not indicate an acute change in the client's condition that would necessitate immediate attention compared to sudden pain relief in a client with severe abdominal pain.
The school nurse is screening students for spinal abnormalities and instructs each student to stand up and then touch their toes. Which finding indicates that a student should be referred for scoliosis evaluation?
- A. Inability to touch their toes
- B. Asymmetry of the shoulders when standing upright
- C. Audible crepitus when bending
- D. An exaggerated upper thoracic convex curvature
Correct Answer: B
Rationale: Asymmetry of the shoulders when standing upright is a common indicator of scoliosis. This finding suggests a possible spinal abnormality and should prompt further evaluation. Choices A, C, and D are not specific indicators of scoliosis. Inability to touch their toes may indicate flexibility issues or tightness in the hamstrings. Audible crepitus when bending may suggest joint degeneration or inflammation. An exaggerated upper thoracic convex curvature could indicate poor posture or other spinal abnormalities but is not directly indicative of scoliosis.
A woman at 24-weeks gestation who has fever, body aches, and has been coughing for the last 5 days is sent to the hospital with admission prescriptions for H1N1 influenza. Which action has the highest priority?
- A. Administer Ringer's Lactate IV 125ml/8 hours
- B. Obtain specimens for cultures
- C. Assign a private room
- D. Monitor vital signs q4 hours
Correct Answer: C
Rationale: Assigning a private room has the highest priority in this scenario. It helps prevent the spread of H1N1 influenza to other patients and protects both the patient and others from potential infection. Obtaining specimens for cultures and monitoring vital signs are important but do not address the immediate need to prevent the spread of the virus. Administering Ringer's Lactate IV is not the priority in this case as it does not directly address the infectious nature of the condition.
A client with multiple sclerosis is experiencing scotomas (blind spots), which are limiting peripheral vision. What intervention should the nurse include in this client's plan of care?
- A. Encourage the use of corrective lenses during the day
- B. Practice visual exercises that focus on a still object
- C. Alternate an eye patch from eye every 2 hours
- D. Teach techniques for scanning the environment
Correct Answer: D
Rationale: The correct intervention for a client with multiple sclerosis experiencing scotomas and limited peripheral vision is to teach techniques for scanning the environment. This intervention helps the client compensate for vision loss by learning how to scan and explore their surroundings effectively. Encouraging the use of corrective lenses may not address the issue of scotomas, and visual exercises focusing on a still object may not enhance peripheral vision. Alternating an eye patch every 2 hours is not typically indicated for scotomas in multiple sclerosis, making it an incorrect choice.
A client is admitted for an exacerbation of heart failure (HF) and is being treated with diuretics for fluid volume excess. In planning nursing care, which interventions should the nurse include? (Select all that apply)
- A. Encourage oral fluid intake of 3,000 ml/day
- B. Observe for evidence of hypokalemia
- C. Teach the client how to restrict dietary sodium
- D. Monitor PTT, PT, and INR lab values
Correct Answer: B
Rationale: The correct interventions to include when a client with heart failure is being treated with diuretics for fluid volume excess are to observe for evidence of hypokalemia. Diuretics can lead to potassium loss, resulting in hypokalemia. Monitoring for this electrolyte imbalance is crucial. Encouraging oral fluid intake of 3,000 ml/day may exacerbate fluid volume excess in a client with heart failure. Teaching the client how to restrict dietary sodium is important in managing heart failure, but it is not directly related to the use of diuretics for fluid volume excess. Monitoring PTT, PT, and INR lab values is not typically associated with diuretic therapy for heart failure but rather with anticoagulant therapy.