Nokea
A client with chest pain is diagnosed with acute pericarditis by the health care provider. The nurse reinforces teaching to the client that the pain will improve with which of the following?
- A. Coughing and deep breathing
- B. Left lateral position
- C. Pursed lip breathing
- D. Sitting up and leaning forward
Correct Answer: D
Rationale: Sitting up and leaning forward reduces pressure on the pericardium, relieving pericarditis pain. Coughing, lateral positioning, and pursed-lip breathing do not alleviate pericardial pain.
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A 4 year-old hospitalized child begins to have a seizure while playing with hard plastic toys in the hallway. Of the following nursing actions, which one should the nurse do first?
- A. Place the child in the nearest bed
- B. Administer IV medication to slow down the seizure
- C. Place a padded tongue blade in the child's mouth
- D. Remove the child's toys from the immediate area
Correct Answer: D
Rationale: Remove the child's toys from the immediate area. Nursing care for a child having a seizure includes, maintaining airway patency, ensuring safety, administering medications, and providing emotional support. Since the seizure has already started, nothing should be forced into the child's mouth and the child should not be moved. Of the choices given, the first priority would be to provide a safe environment.
The LPN is caring for all of the following women on the postpartum unit. Which situation requires further attention?
- A. A woman who gave birth four hours ago has red vaginal drainage on her perineal pad.
- B. The nurse palpates the uterine fundus 3 cm above the umbilicus in a woman who gave birth 12 hours ago.
- C. A woman who had a 20-hour labor and gave birth 8 hours ago asks the nurse not to bring her baby in for breastfeeding during the night.
- D. A woman who gave birth yesterday is sweating profusely and producing large amounts of urine.
Correct Answer: B
Rationale: A fundus 3 cm above the umbilicus 12 hours postpartum suggests uterine atony or retained clots, requiring further assessment to prevent hemorrhage. Other findings are normal or less urgent.
Following a motor vehicle accident, the client does not know where he is or what year it is and has short-term memory impairment. Which nursing action is most appropriate?
- A. Offer several choices to the client.
- B. Give simple directions to the client.
- C. Give the client the details of the care.
- D. Offer written instructions to the client.
Correct Answer: B
Rationale: Simple directions accommodate memory impairment and disorientation, enhancing comprehension and safety post-accident.
A practical nurse (PN) is assigned to care for a newborn with a neural tube defect. Which dressing, if applied by the PN, would need no further intervention by the charge nurse?
- A. Telfa dressing with antibiotic ointment
- B. Moist sterile nonadherent dressing
- C. Dry sterile dressing that is occlusive
- D. Sterile occlusive pressure dressing
Correct Answer: B
Rationale: Before surgical closure, the sac is prevented from drying by the application of a sterile, moist, nonadherent dressing over the defect. Dressings are changed frequently to keep them moist.
The nurse is talking with a client who is entering the second trimester of pregnancy. Which of the following information should the nurse include? Select all that apply.
- A. Anticipate experiencing light fetal movements around 16 to 20 weeks gestation
- B. Increase your consumption of iron-rich foods like meat and dried fruit
- C. Try to gain about 3 lb (1.4 kg) each week if your prepregnancy BMI was normal
- D. Expect to have an abdominal ultrasound scheduled to check fetal anatomy
- E. Plan to be screened for gestational diabetes mellitus around 24 to 28 weeks gestation
Correct Answer: A,B,D,E
Rationale: Fetal movement, iron intake, anatomy ultrasound, and diabetes screening are standard second-trimester recommendations. Weight gain should be about 1 lb/week for normal BMI, not 3 lb.