Nokea
A client telephones the clinic to ask about a home pregnancy test she used this morning. The nurse understands that the presence of which hormone strongly suggests a woman is pregnant?
- A. Estrogen
- B. HCG
- C. Alpha-fetoprotein
- D. Progesterone
Correct Answer: B
Rationale: Human chorionic gonadotropin (HCG) is the biologic marker on which pregnancy tests are based. Reliability is about 98%, but the test does not conclusively confirm pregnancy.
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The nursing assistant reports to the nurse that a client who is one-day postoperative after an angioplasty is refusing to eat and states, 'I just don't feel good.' Which of the following actions, if taken by the nurse, is BEST?
- A. The nurse talks with the client about how he is feeling.
- B. The nurse instructs the nursing assistant to sit with the client while he eats.
- C. The nurse contacts the physician to obtain an order for an antacid.
- D. The nurse evaluates the most recent vital signs recorded in the chart.
Correct Answer: A
Rationale: Assessment is required to determine the cause of the client’s symptoms, as 'not feeling good' could indicate complications such as vessel closure, bleeding, hypotension, or dysrhythmias post-angioplasty. Talking with the client to assess current symptoms is the best initial action. Choices B and C assume causes without assessment, and choice D relies on potentially outdated data.
Cheyne-stokes breathing:
- A. Breathing seen in brain-injured patients.
- B. Shallow, fast with apnea in between.
- C. Deep, rapid breathing seen among patients with increased ICP.
- D. Breathing pattern seen in acidosis.
Correct Answer: A
Rationale: Cheyne-Stokes breathing, with cycles of deep breathing and apnea, is common in brain-injured patients.
Immediately after the procedure, the nurse should:
- A. Position the patient on the affected side.
- B. Begin frequent monitoring of vital signs.
- C. Cleanse the site with an antiseptic solution.
- D. Briefly apply pressure over the aspiration site.
Correct Answer: D
Rationale: Applying pressure prevents bleeding at the aspiration site, a common complication.
A client is given morphine 6 mg IV push for postoperative pain. Following administration of this drug, the nurse observes the following: pulse 68, respirations 8, BP 100/68, client sleeping quietly. Which of the following nursing actions is MOST appropriate?
- A. Allow the client to sleep undisturbed.
- B. Administer oxygen via facemask or nasal prongs.
- C. Administer naloxone (Narcan).
- D. Place epinephrine 1:1,000 at the bedside.
Correct Answer: C
Rationale: A respiratory rate of 8 is dangerously low, indicating opioid-induced respiratory depression, a life-threatening side effect of morphine. Administering naloxone (Narcan) reverses this effect. Allowing the client to sleep risks further respiratory compromise, oxygen may be used after naloxone, and epinephrine is irrelevant.
A client turns her ankle. She is diagnosed as having a Pulled Ligament. This should be documented as a:
- A. sprain.
- B. strain.
- C. subluxation.
- D. distortion.
Correct Answer: B
Rationale: A pulled ligament is documented as a strain, which involves overstretching of a ligament. A sprain involves muscles, and the other terms are incorrect for this injury. Basic Care and Comfort