Nokea
A client who is being evaluated for suspected ectopic pregnancy reports sudden-onset, severe, right lower abdominal pain and dizziness. Which of the following additional assessment findings will the nurse anticipate if the client is experiencing a ruptured ectopic pregnancy? Select all that apply.
- A. Blood pressure 82/64 mm Hg
- B. Crackles on auscultation
- C. Distended jugular veins
- D. Pulse 120/min
- E. Shoulder pain
Correct Answer: A, D, E
Rationale: Low blood pressure (A), tachycardia (D), and shoulder pain (E) indicate hemorrhage from a ruptured ectopic pregnancy. Crackles (B) and jugular vein distension (C) are unrelated.
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The nurse is caring for a client who had a chest tube inserted and attached to portable water seal drainage two days ago. There is no bubbling in the water seal chamber. What should the nurse assess initially?
- A. Observe the wound for excess drainage
- B. Check the system for air leaks
- C. Auscultate the lungs
- D. See if the suction is turned on
Correct Answer: C
Rationale: No bubbling may indicate lung reexpansion or system issues; auscultating lungs assesses reexpansion or complications like pneumothorax. Other assessments are secondary.
The nurse is caring for a client who has bacterial meningitis. Which of the following actions should the nurse take? Select all that apply.
- A. Minimize environmental stimuli.
- B. Implement seizure precautions.
- C. Maintain the head of bed at 30 degrees.
- D. Keep a surgical mask on the client at all times.
- E. Place the client in a room with monitored negative air pressure.
Correct Answer: A, B, C
Rationale: Minimizing stimuli (A), seizure precautions (B), and elevating the head (C) reduce complications in meningitis. Masks (D) are unnecessary, and negative pressure rooms (E) are for airborne diseases.
The nurse reinforces education to the parent of a child who was diagnosed with attention-deficit hyperactivity disorder and received a prescription of methylphenidate. Which statement by the parent best demonstrates that teaching has been effective?
- A. An additive-free, low-sugar diet will reduce my child's symptoms.'
- B. I can now manage my child's condition on my own.'
- C. My child should take the last daily dose of methylphenidate before 6:00 PM.'
- D. Once the medication is started, I will not have to monitor my child anymore.'
Correct Answer: C
Rationale: Taking methylphenidate before 6:00 PM (C) prevents sleep disruption, indicating effective teaching. Diet changes (A), self-management (B), and no monitoring (D) are incorrect or incomplete.
The nurse is reinforcing teaching about home administration of sublingual nitroglycerin tablets to a client with stable angina. Which client statement indicates the need for further teaching?
- A. I can take 1 tablet every 5 minutes, up to 3 times, for chest pain.'
- B. I should call 911 if my chest pain isn't relieved by nitroglycerin.'
- C. I will call my doctor's office if I start experiencing chest pain at rest.'
- D. I will keep one bottle of nitroglycerin in the house and one in the car.'
Correct Answer: D
Rationale: Keeping nitroglycerin in a car (D) risks exposure to heat, reducing efficacy, requiring further teaching. Other statements (A, B, C) are correct.
Which interventions does the nurse perform to promote normal rest and sleep patterns for a critically ill client? Select all that apply.
- A. Dimming the lights at night
- B. Leaving the television on for diversion at night
- C. Opening the window blinds/shades in the morning
- D. Scheduling interventions and activities during the day when possible
- E. Turning off equipment alarms in the client's room at night
Correct Answer: A, C, D
Rationale: Dimming lights (A), opening blinds in the morning (C), and scheduling activities during the day (D) promote circadian rhythms and rest. Leaving the TV on (B) may disrupt sleep, and turning off alarms (E) compromises safety.