Nokea
A client is being admitted to the labor and delivery unit. She has had previous admissions for 'false labor.' Which clinical manifestation would be most indicative of true labor?
- A. Increased bloody show
- B. Progressive dilatation and effacement of the cervix
- C. Uterine contractions
- D. Decreased discomfort with ambulation
Correct Answer: B
Rationale: Contractions of true labor produce progressive cervical effacement and dilatation.
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A patient with a PCA pump (patient controlled analgesia) asks the nurse if he can become overdosed with pain medication using this machine. Which statement made by the nurse is correct?
- A. The machine will administer only the amount of medication needed to control pain without any action from you.'
- B. The machine has a locking device that prevents overdosing.'
- C. The machine will administer one large dose every four hours to relieve your pain.'
- D. The machine is set to deliver medication only if you need it.'
Correct Answer: B
Rationale: PCA pumps have a lockout interval and dose limits programmed to prevent overdose, ensuring safe administration of pain medication. The other statements are inaccurate: PCA requires patient action, does not deliver large doses every four hours, and is not based on ‘need’ detection.
On a mother's 2nd postpartum day after having a vaginal delivery, the RN is preparing to assess her perineum and anus as part of her daily assessment. The best position for the client to be placed in for this assessment is:
- A. Sims'
- B. Fowler's
- C. Prone
- D. Any position that the RN chooses
Correct Answer: A
Rationale: The Sims' position allows optimal exposure of the perineum and anus for assessment by raising the upper buttocks.
The nurse notes the following laboratory test results on a 24-hour post-burn client. Which abnormality should be reported to the physician immediately?
- A. Potassium 7.5 mEq/L
- B. Sodium 131 mEq/L
- C. Arterial pH 7.34
- D. Hematocrit 52%
Correct Answer: A
Rationale: Hyperkalemia (7.5 mEq/L) is life-threatening, risking arrhythmias, and requires immediate reporting. Hyponatremia (B), slightly low pH (C), and elevated hematocrit (D) are less urgent in early burn care.
Following a gastric resection, which of the following actions would the nurse reinforce with the client in order to alleviate the distress from dumping syndrome?
- A. Eating three large meals a day
- B. Drinking small amounts of liquids with meals
- C. Taking a long walk after meals
- D. Eating a low-carbohydrate diet
Correct Answer: D
Rationale: A low-carbohydrate diet prevents a hypertonic bolus, reducing dumping syndrome. The other options exacerbate the condition.
A client with a history of breast cancer is receiving tamoxifen (Nolvadex). Which adverse effect should the nurse monitor for?
- A. Weight loss
- B. Endometrial hyperplasia
- C. Hypotension
- D. Hair loss
Correct Answer: B
Rationale: Tamoxifen increases the risk of endometrial hyperplasia, a serious adverse effect due to its estrogenic effects on the uterus. Weight loss (A), hypotension (C), and hair loss (D) are not typical.