Nokea
A client with a history of a hiatal hernia is being discharged. The nurse should teach the client to:
- A. Sleep in a reclining position
- B. Eat large meals
- C. Avoid carbonated beverages
- D. Lie down after eating
Correct Answer: C
Rationale: Carbonated beverages increase gastric pressure, worsening hiatal hernia symptoms. Sleeping upright, small meals, and avoiding lying down post-meals are also recommended.
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An 11-year-old boy has received a partial-thickness burn to both legs. He presents to the emergency room approximately 15 minutes after the accident in excruciating pain with charred clothing to both legs. What is the first nursing action?
- A. Apply ice packs to both legs.
- B. Begin débridement by removing all charred clothing from wound.
- C. Apply Silvadene cream (silver sulfadiazine).
- D. Immerse both legs in cool water.
Correct Answer: D
Rationale: Emergency care of a thermal burn is immersing both legs in cool water. Cool water permits gradual temperature change and prevents further thermal damage.
The physician has ordered an intravenous infusion of Pitocin for the induction of labor. When caring for the obstetric client receiving intravenous Pitocin,the nurse should monitor for:
- A. Maternal hypoglycemia
- B. Fetal bradycardia
- C. Maternal hyperreflexia
- D. Fetal movement every thirty minutes
Correct Answer: B
Rationale: Pitocin (oxytocin) can cause uterine hyperstimulation leading to reduced placental perfusion and fetal bradycardia (heart rate <110 bpm). Monitoring for fetal bradycardia is critical. Hypoglycemia hyperreflexia and fetal movement frequency are not directly related to Pitocin complications.
A family is experiencing changes in their lifestyle in many ways. The invalid grandmother has moved in with them. The couple have a 2-year-old son by their marriage, and the wife has two children by her previous marriage. The older children are in high school. In applying systems theory to this family, it is important for the nurse to remember which of the following principles?
- A. The parts of a system are only minimally related.
- B. Dysfunction in one part affects every other part.
- C. A family system has no boundaries.
- D. Healthy families are enmeshed.
Correct Answer: B
Rationale: Any change in any part of the system affects all other parts.
A 74-year-old female client is 3 days postoperative. She has an indwelling catheter and has been progressing well. While the nurse is in the room, the client states, 'Oh dear, I feel like I have to urinate again!' Which of the following is the most appropriate initial nursing response?
- A. Assure her that this is most likely the result of bladder spasms.
- B. Check the collection bag and tubing to verify that the catheter is draining properly.
- C. Instruct her to do Kegel exercises to diminish the urge to void.
- D. Ask her if she has felt this way before.
Correct Answer: B
Rationale: The most frequent reason for an urge to void with an indwelling catheter is blocked tubing, so checking the catheter's patency is the best initial response.
Which finding is considered a risk factor in the development of leukemia?
- A. The client is an avid stamp collector.
- B. The client works as a computer programmer.
- C. The client had radiation for Hodgkin's lymphoma.
- D. The client's grandmother had stomach cancer.
Correct Answer: C
Rationale: Radiation exposure such as from treatment for Hodgkin’s lymphoma is a known risk factor for leukemia. Stamp collecting computer programming and a family history of stomach cancer are not established risk factors.