Nokea
A client who has had three spontaneous abortions is requesting information about possible causes. The nurse's response should be based on which information?
- A. Chromosomal abnormalities are the most common cause of early spontaneous abortions
- B. Incompetent cervix can cause spontaneous abortions
- C. An infection can cause spontaneous abortions
- D. Nutritional deficiencies are the most common cause of early spontaneous abortions
Correct Answer: A
Rationale: The correct answer is A because chromosomal abnormalities are indeed the most common cause of early spontaneous abortions. These abnormalities can occur during fertilization or early cell division, leading to non-viable embryos. Choice B, incompetent cervix, typically causes late-term miscarriages. Choice C, infections, can contribute to miscarriages but are not the most common cause. Choice D, nutritional deficiencies, can impact pregnancy outcomes but are not the primary cause of early spontaneous abortions. In summary, the correct answer A is supported by the fact that chromosomal abnormalities are the leading cause of early spontaneous abortions, while the other choices are either more relevant to late-term miscarriages or less commonly associated with early pregnancy loss.
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The nurse is planning discharge teaching for a client with chronic kidney disease. Which information is most important for the nurse to provide this client?
- A. Monitor daily weights
- B. Limit fluid intake to prevent fluid overload
- C. Report any weight gain of more than 2 pounds in a day
- D. Increase protein intake to promote healing
Correct Answer: C
Rationale: Rationale: Choice C is correct because sudden weight gain can indicate fluid retention, a common complication in chronic kidney disease. This can lead to serious issues like heart failure. Monitoring weight daily (A) is important, but specifically reporting significant gains promptly (C) is crucial. Limiting fluid intake (B) is important, but not the top priority. Increasing protein intake (D) may worsen kidney function, so it's not recommended.
A 59-year-old male client is brought to the emergency room where he is assessed to have a Glasgow Coma Scale of 3. Based on this assessment, how should the nurse characterize the client's condition?
- A. The client is experiencing increased intracranial pressure
- B. He has a good prognosis for recovery
- C. This client is conscious, but is not oriented to time and place
- D. He is in a coma, and has a very poor prognosis
Correct Answer: D
Rationale: The correct answer is D because a Glasgow Coma Scale score of 3 indicates deep unconsciousness, which is classified as a coma. A GCS score of 3 signifies the lowest possible level of consciousness and is associated with a very poor prognosis due to the severity of neurological impairment. Choices A, B, and C are incorrect. Increased intracranial pressure may be present in comatose patients but is not solely indicated by a GCS score of 3. A good prognosis is unlikely with a GCS score of 3. Being unconscious with a GCS score of 3 does not equate to being conscious but disoriented as in choice C.
A client who has a new prescription for warfarin (Coumadin) asks the nurse how the medication works. What explanation should the nurse provide?
- A. It dissolves blood clots
- B. It prevents the blood from clotting
- C. It thins the blood
- D. It decreases the risk of infection
Correct Answer: B
Rationale: The correct answer is B: It prevents the blood from clotting. Warfarin works as an anticoagulant by inhibiting the production of certain clotting factors in the liver. This prevents the formation of blood clots and reduces the risk of conditions like deep vein thrombosis or stroke. Choice A is incorrect because warfarin does not dissolve existing blood clots but prevents new ones. Choice C is misleading as it does not actually "thin" the blood but affects its ability to clot. Choice D is unrelated to the mechanism of action of warfarin.
The nurse is caring for a laboring 22-year-old primigravida following administration of regional anesthesia. In planning care for this client, what nursing intervention has the highest priority?
- A. Raising the side rails and placing the call bell within reach
- B. Teaching the client how to push effectively to decrease the length of the second stage of labor
- C. Timing and recording uterine contractions
- D. Positioning the client for proper distribution of anesthesia
Correct Answer: A
Rationale: The correct answer is A because raising the side rails and placing the call bell within reach ensures the safety and immediate accessibility of the client, which is the highest priority in nursing care. This intervention helps prevent falls or other accidents and allows the client to call for assistance if needed.
Choice B is incorrect because teaching pushing techniques is important but not the highest priority at this moment. Choice C, timing and recording uterine contractions, is also important but not the highest priority compared to ensuring the client's safety. Choice D, positioning for anesthesia distribution, is relevant but not as critical as ensuring immediate access to assistance in case of emergency.
A client who has a flaccid bladder is placed on a bladder training program. Which instruction should the nurse include in this client's teaching plan?
- A. Use manual pressure to express urine
- B. Perform the Crede maneuver
- C. Apply an external urinary drainage device
- D. Take a warm sitz bath twice a day
Correct Answer: B
Rationale: The correct answer is B: Perform the Crede maneuver. This is the appropriate instruction for a client with a flaccid bladder on a bladder training program. The Crede maneuver involves applying manual pressure on the bladder to assist with urine elimination. This technique helps to promote bladder emptying and prevent urinary retention.
A: Using manual pressure to express urine is not recommended as it can lead to urinary tract infections and damage to the bladder.
C: Applying an external urinary drainage device is not part of bladder training and does not address the issue of bladder emptying.
D: Taking a warm sitz bath twice a day does not directly address the client's flaccid bladder and is not a component of bladder training.