Nokea
A client is admitted to the labor and delivery unit. The nurse performs a vaginal exam and determines that the client's cervix is 5cm dilated with 75% effacement. Based on the nurse's assessment the client is in which phase of labor?
- A. Active
- B. Latent
- C. Transition
- D. Early
Correct Answer: A
Rationale: A cervix dilated to 5 cm with 75% effacement indicates the active phase of labor.
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Intra-arterial chemotherapy primarily benefits the client by applying greater concentrations of medication directly to the malignant tumor. An additional benefit of intra-arterial chemotherapy is:
- A. Prevention of nausea and vomiting
- B. Treatment of micro-metastasis
- C. Eradication of bone pain
- D. Prevention of therapy-induced anemia
Correct Answer: B
Rationale: Intra-arterial chemotherapy can treat micro-metastases by delivering high drug concentrations to the tumor and surrounding areas.
A client with Alzheimer's disease is awaiting placement in a skilled nursing facility. Which long-term plans would be most therapeutic for the client?
- A. Placing mirrors in several locations in the home
- B. Placing a picture of herself in her bedroom
- C. Placing simple signs to indicate the location of the bedroom, bathroom, and so on
- D. Alternating healthcare workers to prevent boredom
Correct Answer: C
Rationale: Simple signs help orient clients with Alzheimer's, reducing confusion and promoting independence in a new environment.
A patient is rushed to the emergency room after being found unconscious at home. His blood pressure is 70/35. The nurse anticipates an order for what medication?
- A. atropine sulfate (Atropine)
- B. amiodarone (Cordarone)
- C. magnesium sulfate
- D. adenosine (Adenoscan)
- E. None
- F. All the above
Correct Answer: E
Rationale: For severe hypotension (BP 70/35), vasopressors like norepinephrine or dopamine are typically ordered to restore perfusion, but none of the listed options are vasopressors. The question may be flawed.
The nurse is caring for a client with peripheral vascular disease. To correctly assess the oxygen saturation level, the monitor may be placed on the:
- A. Hip
- B. Ankle
- C. Earlobe
- D. Chin
Correct Answer: C
Rationale: The earlobe is a suitable site for pulse oximetry in peripheral vascular disease, as it is less affected by impaired peripheral circulation.
The physician has prescribed Novalog insulin for a client with diabetes mellitus. Which statement indicates that the client knows when the peak action of the insulin occurs?
- A. I will make sure I eat breakfast within 10 minutes of taking my insulin.
- B. I will need to carry candy or some form of sugar with me all the time.
- C. I will eat a snack around three o'clock each afternoon.
- D. I can save my dessert from supper for a bedtime snack.
Correct Answer: C
Rationale: Novolog insulin peaks around 1-3 hours after administration, so a snack around 3 PM aligns with the peak to prevent hypoglycemia.