Nokea
A client with hemophilia has a nosebleed. Which nursing action is most appropriate to control the bleeding?
- A. Place the client in a sitting position.
- B. Administer acetaminophen (Tylenol).
- C. Pinch the soft lower part of the nose.
- D. Apply ice packs to the forehead.
Correct Answer: C
Rationale: Pinching the soft lower part of the nose is the most effective way to control a nosebleed in a client with hemophilia, as it applies direct pressure to the bleeding site.
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A labor and delivery nurse is caring for a client in active labor. The fetal monitor shows late decelerations. The nurse should first
- A. place the client in high-Fowler's position in preparation to push.
- B. place the client in left lateral recumbent position.
- C. increase the rate of IV Pitocin.
- D. call the physician and report fetal distress.
Correct Answer: B
Rationale: Late decelerations indicate uteroplacental insufficiency. The left lateral position improves placental perfusion, addressing the immediate cause.
A 6-month-old client is admitted with possible intussuception. Which question during the nursing history is least helpful in obtaining information regarding this diagnosis?
- A. Tell me about his pain.
- B. What does his vomit look like?
- C. Describe his usual diet.
- D. Have you noticed changes in his abdominal size?
Correct Answer: C
Rationale: The usual diet is less directly related to diagnosing intussusception compared to symptoms like pain, vomiting, or abdominal changes.
The nurse is caring for a client receiving peritoneal dialysis. Which of the following assessment findings would require an intervention by the nurse?
- A. Abdominal discomfort during infusion of dialysate.
- B. Presence of constipation.
- C. Cloudy dialysate output.
- D. Ecchymosis around peritoneal catheter.
Correct Answer: C
Rationale: indicates peritonitis, also will see nausea and vomiting, anorexia, abdominal pain, tenderness, rigidity
The registered nurse is making assignments for the day. Which client should be assigned to the pregnant nurse?
- A. The client with HIV
- B. The client with a radium implant for cervical cancer
- C. The client with RSV (respiratory syncytial virus)
- D. The client with cytomegalovirus
Correct Answer: C
Rationale: The client with RSV poses the least risk to a pregnant nurse, as it is a common respiratory virus, whereas HIV, radium implants, and cytomegalovirus carry higher risks during pregnancy.
According to Maslow's hierarchy of needs, order the following needs from most basic to most advanced (bottom of the pyramid to the top):
- A. safety and security
- B. esteem
- C. physiological
- D. love and belonging
- E. self-actualization
Correct Answer: C,A,D,B,E
Rationale: Maslow’s hierarchy: physiological (most basic), safety and security, love and belonging, esteem, self-actualization (most advanced).