Nokea
A client with a history of pancreatitis is admitted with complaints of nausea. The nurse should give priority to:
- A. Administering antiemetics
- B. Monitoring blood pressure
- C. Administering pain medication
- D. Monitoring respiratory rate
Correct Answer: A
Rationale: Antiemetics relieve nausea in pancreatitis, improving comfort and preventing dehydration.
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The surgical nurse is preparing a patient for surgery on the lower abdomen. In which position would the nurse most likely place the client for surgery on this area?
- A. Lithotomy
- B. Sim's
- C. Prone
- D. Trendelenburg
Correct Answer: A
Rationale: The lithotomy position is used for lower abdominal surgeries (e.g., gynecologic procedures) to provide access to the pelvic area. Sim's (B) is for rectal exams, prone (C) for back surgeries, and Trendelenburg (D) for shock or upper abdominal access.
A 34-year-old client who is gravida 1, para 0 has a history of infertility and conceived this pregnancy while taking fertility drugs. She is at 32 weeks' gestation and is carrying triplets. She is complaining of low back pain and a feeling of pelvic pressure. Her cervical exam reveals a long, closed cervix. The nurse notes that the client is experiencing mild uterine contractions every 7-8 minutes after the nurse has placed her on the fetal monitor. Her condition should indicate that:
- A. Her cervix shows she will likely deliver soon
- B. The nurse should not be alarmed because mild uterine activity is common at 32 weeks' gestation
- C. She may be in preterm labor because this is more common with multiple pregnancies
- D. She most likely has a urinary tract infection (UTI) because this is common with pregnancy
Correct Answer: C
Rationale: Rhythmical contractions in conjunction with low back pain and pelvic pressure at 32 weeks in a woman carrying triplets are of great concern, indicating possible preterm labor, which is more common in multiple pregnancies.
A client with a history of a stroke is being discharged. The client’s wife asks the nurse how long it will take for her husband to regain his speech. The nurse’s response is based on the knowledge that:
- A. Speech therapy must begin immediately
- B. Most speech recovery occurs within 6 months
- C. Speech recovery cannot be predicted
- D. Speech therapy is not effective after 3 months
Correct Answer: B
Rationale: Most speech recovery post-stroke occurs within the first 6 months, though progress can continue with therapy. Recovery varies, but 6 months is a key period for significant improvement.
A vaginal exam of a laboring client reveals that the fetus is at 0 station. This assessment means that:
- A. The fetus has not descended into the birth canal.
- B. The fetus is in a transverse lie.
- C. The fetus is level with the ischial spines.
- D. The fetus is at increased risk for precipitate delivery.
Correct Answer: C
Rationale: A 0 station means the presenting part of the fetus is level with the ischial spines indicating engagement in the pelvis. It does not indicate a lack of descent transverse lie or immediate risk of precipitate delivery.
A registered nurse is trying to determine the appropriate care that she should provide for her obstetrical clients. Which of the following documents is considered the legal standard of practice?
- A. State nursing practice act
- B. AWHONN Standards for the Nursing Care of Women and Newborns
- C. American Nurses' Association Standards of Maternal-Child Health Nursing
- D. International Council of Nurses' Code
Correct Answer: A
Rationale: The state nursing practice act determines the standard of care for the professional nurse. AWHONN Standards are published as recommendations and guidelines for maternal-newborn nursing. American Nurses' Association Standards are published as recommendations and guidelines for maternal-child health nursing. The International Council of Nurses' Code emphasizes the nurse's obligations to the client rather than to the physician. It is published as recommendations and guidelines by the international organization for professional nursing.