Nokea
A multigravid client at 34 weeks' gestation who is leaking amniotic fluid has just been hospitalized with a diagnosis of preterm premature rupture of membranes and preterm labor. The client's contractions are 20 minutes apart, lasting 20 to 30 seconds. Her cervix is dilated to 2 cm. The nurse reviews the physician orders (see chart). Which of the following orders should the nurse initiate first?
- A. Initiate fetal and contraction monitoring
- B. Start the intravenous infusion
- C. Obtain the urine specimen
- D. Administer betamethasone
Correct Answer: A
Rationale: Fetal and contraction monitoring is the priority to assess fetal well-being and labor progression, guiding further interventions.
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You are having a nice dinner in a fancy restaurant. As you are eating, you hear the gentleman eating at the next table start to bang the table, hold his throat and forcibly cough. What should you do?
- A. Perform the Valsalva maneuver
- B. Encourage the person to continue coughing
- C. Perform the Heimlich maneuver
- D. Begin CPR and prepare for ACLS measures
Correct Answer: B
Rationale: Forcing coughing suggests a partial airway obstruction. Encouraging the person to continue coughing is the first step to dislodge the obstruction without invasive intervention.
A client with a history of cirrhosis is admitted with hepatic encephalopathy. The nurse should include which of the following in the plan of care?
- A. Administer lactulose as prescribed.
- B. Encourage a high-protein diet.
- C. Restrict fluid intake.
- D. Administer sedatives for agitation.
Correct Answer: A
Rationale: Lactulose reduces ammonia levels in hepatic encephalopathy.
The nurse is teaching a client who is taking insulin about the signs of diabetic ketoacidosis, which include:
- A. Kussmaul's respirations
- B. Excessive hunger
- C. Dry, flaky skin
- D. High blood pressure
Correct Answer: A
Rationale: Kussmaul's respirations (rapid, deep breathing) are a hallmark of diabetic ketoacidosis as the body compensates for acidosis. Excessive hunger is more typical of hypoglycemia, and dry skin or hypertension are less specific.
The nurse is teaching a client with gastroesophageal reflux disease (GERD) about lifestyle modifications. Which statement indicates understanding?
- A. I should eat large meals to avoid snacking.'
- B. I will sleep flat to relax my stomach.'
- C. I'll avoid lying down for 2 hours after eating.'
- D. I can drink orange juice with breakfast.'
Correct Answer: C
Rationale: Avoiding lying down for 2 hours after eating prevents acid reflux by keeping the stomach contents below the esophagus.
A client with a history of type 1 diabetes is prescribed insulin aspart (NovoLog). The nurse should instruct the client to:
- A. Take the insulin 5–10 minutes before meals.
- B. Mix the insulin with long-acting insulin.
- C. Take the insulin at bedtime.
- D. Stop the insulin if blood glucose normalizes.
Correct Answer: A
Rationale: Insulin aspart, a rapid-acting insulin, is taken 5–10 minutes before meals for prandial coverage.