Nokea
A client with pregnancy-induced hypertension is scheduled for a C-section. Before surgery, the nurse should keep the client:
- A. On her right side
- B. Supine with a small pillow
- C. On her left side
- D. In knee chest position
Correct Answer: C
Rationale: The left lateral position improves uterine perfusion and reduces pressure on the vena cava in clients with pregnancy-induced hypertension.
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A client with bacterial pneumonia is admitted to the pediatric unit. What would the nurse expect the admitting assessment to reveal?
- A. High fever
- B. Nonproductive cough
- C. Rhinitis
- D. Vomiting and diarrhea
Correct Answer: A
Rationale: High fever is a hallmark of bacterial pneumonia due to the body's response to infection.
A child who ingested 18 500-mg acetaminophen tablets 30 minutes ago is seen in the ED. Which of these orders should the nurse do first?
- A. activated charcoal per pharmacy
- B. start an IV with D5W to keep the vein open
- C. gastric lavage PRN
- D. acetylcysteine (Mucomyst) for age per pharmacy
Correct Answer: A
Rationale: Activated charcoal is the priority within 1 hour of acetaminophen overdose to reduce absorption, followed by acetylcysteine to prevent liver damage.
The nurse is making assignments for the day. The staff consists of an RN, an LPN, and a nursing assistant. Which client could the nursing assistant care for?
- A. A client with Alzheimer's disease
- B. A client with pneumonia
- C. A client with appendicitis
- D. A client with thrombophlebitis
Correct Answer: A
Rationale: Alzheimer's patients require basic care, suitable for a nursing assistant.
Which cephalic presentation is most common during delivery of a neonate?
- A. Vertex
- B. Face
- C. Military
- D. Brow
Correct Answer: A
Rationale: Vertex presentation (A), with the head flexed and occiput leading, is the most common (95%) during delivery.
The nurse is auscultating a client's breath sounds. Low-pitched grating and rubbing are noted on inhalation and exhalation. What will the nurse chart under assessment findings?
- A. ronchi
- B. stridor
- C. friction rub
- D. fine crackles
Correct Answer: C
Rationale: Low-pitched grating/rubbing sounds indicate a pleural friction rub, often due to pleural inflammation.