Nokea
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing.
- A. Ensure that client has intake of at least 200mL/hr
- B. Initiate contact precautions
- C. Prepare client for light therapy
- D. Sickle cell crisis
- E. Psoriasis
- F. Osteomyelitis
Correct Answer: B,C
Rationale: Increased fluid intake and contact precautions are essential for managing systemic lupus erythematosus.
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Which statement indicates understanding of the teaching?
- A. A transcutaneous electrical nerve stimulator will help with pelvic pressure
- B. I can use my ultrasound picture as a focal point during contractions
- C. Breathing techniques can help me stay relaxed during contractions
- D. Changing positions frequently can reduce my discomfort
- E. A warm shower or bath may help ease my labor pain
Correct Answer: C
Rationale: The correct answer is C because it demonstrates understanding of the teaching on coping strategies during labor. Breathing techniques are commonly taught to help manage pain and promote relaxation during contractions. This choice aligns with established labor preparation methods. Other choices lack direct relevance to labor pain management. A focuses on a specific device rather than coping mechanisms. B focuses on a visual aid, which may not address pain management directly. D mentions changing positions, which is beneficial but not as directly related to relaxation techniques. E mentions a warm shower or bath, which can help with pain relief but doesn't specifically address relaxation techniques for coping with contractions.
After the nurse indicates chest pain protocol, which of the following is the priority diagnostic test?
- A. PT and INR
- B. 12 lead ECG
- C. Chest X-ray
- D. D-dimer test
Correct Answer: C
Rationale: The correct answer is C: Chest X-ray. When a patient presents with chest pain, a chest X-ray is crucial to evaluate for any acute cardiopulmonary conditions like pneumonia, pneumothorax, or aortic dissection. It helps identify any immediate life-threatening issues that require prompt intervention. PT and INR (A) are coagulation tests not typically indicated for acute chest pain. A 12-lead ECG (B) is important but usually done after the chest X-ray to assess for cardiac abnormalities. D-dimer test (D) is used to rule out pulmonary embolism, but it is not the priority test in the initial evaluation of chest pain.
The nurse should instruct the client about which of the following medications?
- A. Ranitidine
- B. Vitamin B
- C. Metoclopramide
- D. Vitamin K
Correct Answer: B
Rationale: The correct answer is B: Vitamin B. The nurse should instruct the client about Vitamin B because it plays a crucial role in various bodily functions such as energy production, nerve function, and red blood cell formation. Deficiency in Vitamin B can lead to various health issues. Ranitidine, Metoclopramide, and Vitamin K are specific medications that are not typically instructed by nurses unless prescribed by a healthcare provider for specific conditions. Vitamin K is essential for blood clotting, but its education is usually provided by healthcare providers for specific cases.
Which of the following actions should the nurse take?
- A. Obtain the specimen immediately upon the client waking up.
- B. Wait 1 day to collect the specimen if the client cannot provide sputum.
- C. Ask the client to provide 15 to 20 ml of sputum in the container.
- D. Wear sterile gloves to collect specimen from the client.
Correct Answer: A
Rationale: The correct answer is A because obtaining the specimen immediately upon the client waking up is crucial for accurate results in sputum collection. In the morning, the sputum is usually more concentrated and provides a better sample. Waiting or collecting at other times may lead to diluted or contaminated samples, affecting test results. Choice B is incorrect as it suggests delaying collection, which could compromise the accuracy of the test. Choice C is incorrect because the amount specified is too high for sputum collection, risking contamination. Choice D is incorrect as sterile gloves are not always necessary for sputum collection, regular gloves are usually sufficient.
Which type of insulin should the nurse anticipate administering?
- A. Glargine insulin.
- B. Regular insulin.
- C. NPH insulin.
- D. Insulin aspart.
Correct Answer: A
Rationale: The correct answer is A: Glargine insulin because it is a long-acting insulin with a duration of action of up to 24 hours, providing a basal level of insulin throughout the day. It is typically administered once daily at the same time each day to maintain stable blood glucose levels. Regular insulin (B) is short-acting and is usually given before meals. NPH insulin (C) is intermediate-acting and has a peak action of 4-12 hours. Insulin aspart (D) is a rapid-acting insulin used for mealtime coverage. In this scenario, the nurse should anticipate administering Glargine insulin for its long-acting, basal properties.