Nokea
A gravida III para II is admitted to the labor unit. Vaginal exam reveals that the client's cervix is 8 cm dilated, with complete effacement. The priority nursing diagnosis at this time is:
- A. Alteration in coping related to pain
- B. Potential for injury related to precipitate delivery
- C. Alteration in elimination related to anesthesia
- D. Potential for fluid volume deficit related to NPO status
Correct Answer: B
Rationale: At 8 cm dilation with complete effacement, the client is in advanced labor, and the risk of precipitate delivery is high, posing a potential for injury.
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The nurse is preparing a client for discharge following the removal of a cataract. The nurse should tell the client to:
- A. Take aspirin for discomfort
- B. Avoid bending over to put on his shoes
- C. Remove the eye shield before going to sleep
- D. Continue showering as usual
Correct Answer: B
Rationale: Avoiding bending over prevents increased intraocular pressure post-cataract surgery.
Which of the following is a characteristic of an ominous periodic change in the fetal heart rate?
- A. A fetal heart rate of 120-130 bpm
- B. A baseline variability of 6-10 bpm
- C. Accelerations in FHR with fetal movement
- D. A recurrent rate of 90-100 bpm at the end of the contractions.
Correct Answer: D
Rationale: A recurrent fetal heart rate of 90-100 bpm at contraction ends indicates severe distress, an ominous sign.
The nurse is caring for a client with a tracheostomy tube in place. During tracheostomy care, the nurse accidentally dislodges the tube. Which of the following actions should the nurse take FIRST?
- A. Insert a new tracheostomy tube immediately.
- B. Call for assistance from the respiratory therapist.
- C. Attempt to reinsert the dislodged tube.
- D. Cover the stoma with a sterile dressing.
Correct Answer: A
Rationale: immediate reinsertion of a tracheostomy tube is critical to maintain airway patency
An electrical fire occurs in a client's room shortly after the client returns from the recovery room after repair of a hip fracture with insertion of a prosthesis. What is the best method of removing the client from the room?
- A. Place the client in a wheelchair.
- B. Transfer the client to a gurney.
- C. Move the bed with the client on it.
- D. Do a two-person carry.
Correct Answer: C
Rationale: Moving the bed with the client on it (C) is the safest and fastest method to evacuate a post-surgical client with limited mobility during an emergency like a fire. Other methods (A, B, D) risk injury or delay.
The charge nurse on a surgical unit incorporates an authoritative style of leadership. Which characteristics describe this style of leadership? Select all that apply.
- A. involves little planning
- B. motivates staff by coercion
- C. motivates staff by supporting their achievements
- D. involves communication flow down the chain of command
- E. includes group members in the decision-making process
Correct Answer: B, D
Rationale: Authoritative leadership involves top-down communication and can use coercion to motivate, focusing on control rather than collaboration or support.