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A diabetic primigravid client at 38 weeks' gestation asks the nurse why she had a fetal acoustic stimulation during her last nonstress test. Which of the following should the nurse include as the rationale for this test?
- A. To listen to the fetal heart rate
- B. To startle and awaken the fetus
- C. To stimulate mild contractions
- D. To confirm amniotic fluid amount
Correct Answer: B
Rationale: Fetal acoustic stimulation is used to startle and awaken the fetus, prompting movement to assess fetal heart rate reactivity during a nonstress test. It does not directly measure heart rate, stimulate contractions, or assess amniotic fluid.
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Select the complication of intravenous therapy that is accurately paired with one of its interventions.
- A. Infection: Lowering the limb to promote circulation
- B. Infiltration: The application of cold to the site
- C. Extravasation: The aspiration of contents including blood from the IV cannula
- D. Hematoma: The administration of dexrazoxane
Correct Answer: C
Rationale: Aspirating contents from the IV cannula is an intervention for extravasation to remove vesicant drugs and minimize tissue damage.
The doctor orders a midstream urine specimen for your client who is an alert, oriented and ambulatory female client. What element should you include in your instructions to this client on the proper manner to collect this specimen?
- A. The need to cleanse the perineal area with circular wipes.
- B. The need to cleanse the perineal area from the 'dirtiest' to the 'cleanest'.
- C. The need to use a new antiseptic wipe for each wipe from the inner to the outer labia.
- D. The need to use a new antiseptic wipe for each wipe from the outer to the inner labia.
Correct Answer: C
Rationale: For a midstream urine specimen, the perineal area should be cleansed from front to back (inner to outer labia) using a new antiseptic wipe for each stroke to prevent contamination.
Place the phases or stages of the inflammatory response in the correct sequential order, do NOT include any phases that is NOT part of the inflammatory process. 1. The vascular phase 2. The prodromal phase 3. The incubation phase 4. The initial injury 5. The exudate phase 6. The convalescence phase
- A. 4,2,1
- B. 4,1,5
- C. 4,5,1
- D. 4,2,5
Correct Answer: B
Rationale: The inflammatory response includes the initial injury (4), followed by the vascular phase (1, vasodilation and increased permeability), and then the exudate phase (5, fluid and cell migration). Prodromal (2), incubation (3), and convalescence (6) are not part of the inflammatory process. Thus, B (4,1,5) is correct.
One of the primary purposes of a formal medication reconciliation is to:
- A. Prevent polypharmacy
- B. Conserve financial resources
- C. Prevent interactions
- D. Prevent allergies
Correct Answer: C
Rationale: Medication reconciliation compares current and previous medication lists to identify and prevent potential drug interactions, ensuring safe prescribing.
You have been asked to teach an inservice class for nurses in your facility about ethics. Which of the following should you consider during the planning of this educational activity?
- A. Planning a way to evaluate the effectiveness of the class by seeing a decrease in the amount of referrals to the facility's Ethics Committee
- B. Establishing educational objectives for the class that reflect the methods and methodology that you will use to present the class content
- C. The need to exclude case studies from the class because this would violate client privacy and confidentiality
- D. Some of the most commonly occurring bioethical concerns including genetic engineering into the course content
Correct Answer: B
Rationale: When planning an educational activity, establishing clear educational objectives is essential to define the content, methods, and expected outcomes of the class, ensuring effective learning.