Nokea
A female client presents to the obstetric-gynecology clinic for a pregnancy test, the result which turns out to be positive. Her last menstrual period began December 10, 1993. Using Nägele's rule, the nurse estimates her date of delivery to be:
- A. 17-Sep-94
- B. 10-Sep-94
- C. 3-Sep-94
- D. 17-Aug-94
Correct Answer: A
Rationale: According to Nägele's rule, the estimated date of delivery is calculated by adding 7 days to the date of the first day of the normal menstrual period (December 10 + 7 days = December 17), and then by counting back 3 months (December 17 - 3 mo = September 17). (B, C, D) These answers are incorrect.
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The nurse is teaching a client with a history of lactose intolerance about dietary modifications. The nurse should tell the client to avoid:
- A. Dairy products
- B. High-fiber foods
- C. Lean meats
- D. Fresh fruits
Correct Answer: A
Rationale: Dairy products contain lactose, which causes gastrointestinal symptoms in lactose intolerance, so they should be avoided.
A 65-year-old client is admitted after a stroke. Which nursing intervention would best improve tissue perfusion to prevent skin problems?
- A. Assessing the skin daily for breakdown
- B. Massaging any erythematous areas on the skin
- C. Changing incontinence pads as soon as they become soiled with urine or feces
- D. Performing range-of-motion exercises and turning and repositioning the client
Correct Answer: D
Rationale: Performing range-of-motion exercises and turning/repositioning enhances blood flow to tissues, reducing the risk of pressure ulcers by relieving pressure points. Assessing skin (A) is monitoring, not an intervention to improve perfusion. Massaging erythematous areas (B) can worsen tissue damage. Changing pads (C) prevents irritation but doesn’t directly improve perfusion.
Which type of insulin can be administered by a continuous IV drip?
- A. Humulin N
- B. NPH insulin
- C. Regular insulin
- D. Lente insulin
Correct Answer: C
Rationale: Regular insulin is the only insulin that can be administered IV.
Following a gastric resection, a 70-year-old client is admitted to the postanesthesia care unit. He was extubated prior to leaving the suite. On arrival at the postanesthesia care unit, the nurse should:
- A. Check airway, feeling for amount of air exchange noting rate, depth, and quality of respirations
- B. Obtain pulse and blood pressure readings noting rate and quality of pulse
- C. Reassure the client that his surgery is over and that he is in the recovery room
- D. Review physician's orders, administering medications as ordered
Correct Answer: A
Rationale: Adequate air exchange and tissue oxygenation depend on competent respiratory function. Checking the airway is the nurse's priority action. Obtaining the vital signs is an important action, but it is secondary to airway management. Reorienting a client to time, place, and person after surgery is important, but it is secondary to airway and vital signs. Airway management takes precedence over physician's orders unless they specifically relate to airway management.
Which of the following risk factors associated with breast cancer would a nurse consider most significant in a client's history?
- A. Menarche after age 13
- B. Nulliparity
- C. Maternal family history of breast cancer
- D. Early menopause
Correct Answer: C
Rationale: Women who begin menarche late (after 13 years old) have a lower risk of developing breast cancer than women who have begun earlier. Average age for menarche is 12.5 years. Women who have never been pregnant have an increased risk for breast cancer, but a positive family history poses an even greater risk. A positive family history puts a woman at an increased risk of developing breast cancer. It is recommended that mammography screening begin 5 years before the age at which an immediate female relative was diagnosed with breast cancer. Early menopause decreases the risk of developing breast cancer.