Nokea
A non-stress test has been ordered for a pregnant client with diabetes mellitus. Non-stress testing is a part of the diabetic's prenatal care because:
- A. Fetal movement is adversely affected by diabetes.
- B. Maternal insulin levels can have a negative effect on fetal energy.
- C. Diabetes can adversely affect development of placental vessels.
- D. Fetal lung maturity is most easily determined by non-stress testing.
Correct Answer: C
Rationale: Diabetes can impair placental vessel development, reducing oxygen and nutrient delivery to the fetus, necessitating non-stress testing to monitor fetal well-being. Fetal movement and lung maturity are assessed differently, and insulin's effect is indirect.
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Which of the following nursing interventions is essential when caring for a client who is receiving Cyclophosphamide (Cytoxin)?
- A. Monitoring vital signs q 1 hour
- B. Carefully monitoring of urine output
- C. Monitoring apical pulse
- D. Assessing for signs of increased intracranial pressure
Correct Answer: B
Rationale: Cyclophosphamide can cause hemorrhagic cystitis; monitoring urine output is critical to detect blood in the urine and ensure adequate hydration.
The nurse is caring for a hospice client with advanced heart failure who is having trouble breathing. Which comfort intervention should the nurse implement first?
- A. Administer PRN albuterol by nebulizer
- B. Assist with guided imagery to relieve anxiety
- C. Elevate the head of the bed
- D. Give PRN sublingual morphine
Correct Answer: C
Rationale: Elevating the head of the bed (C) is the first non-pharmacologic intervention to ease breathing in heart failure by reducing pulmonary congestion. Albuterol (A) is for bronchospasm, imagery (B) is secondary, and morphine (D) is for severe distress.
The charge nurse in a long-term memory care facility is making assignments for the Alzheimer unit. Which tasks may be delegated to experienced unlicensed assistive personnel? Select all that apply.
- A. Assisting clients with bathing and hair care
- B. Evaluating safety hazards in clients' rooms
- C. Monitoring clients for behavioral changes
- D. Placing bed alarms at night for clients at risk for wandering
- E. Reporting a client's swallowing difficulties during mealtime
Correct Answer: A,D,E
Rationale: Bathing/hair care (A), placing bed alarms (D), and reporting swallowing issues (E) are within UAP scope. Evaluating hazards (B) and monitoring behavior changes (C) require nursing judgment.
The nurse is caring for a client with a tracheostomy who has an order to begin oral intake. Which of the following actions should the nurse take to decrease the client's risk for aspiration?
- A. Fully inflate the tracheostomy cuff before the client begins to eat.
- B. Encourage the client to use a straw when drinking fluids.
- C. Instruct the client to tilt the head back when swallowing
- D. Provide thickened liquids for the client.
Correct Answer: D
Rationale: Thickened liquids (D) reduce aspiration risk by slowing transit. Inflating the cuff (A) is not always necessary, straws (B) may increase risk, and tilting the head back (C) worsens aspiration.
A nursing advocate is one who:
- A. makes decisions for others.
- B. encourages persons to make decisions for themselves and acts with or on behalf of the person to support those decisions.
- C. manages the care of others.
- D. is the legal representative for a person.
Correct Answer: B
Rationale: Nurse advocates work with clients to provide information and assistance is decision-making. The decisions and care that occur from these decisions are based on the right of the client to self-determination.