Nokea
A nulligravid client calls the clinic and tells the nurse that she forgot to take her oral contraceptive in the morning. Which of the following should the nurse instruct the client to do?
- A. Take the medication immediately.
- B. Restart the medication in the morning.
- C. Use another form of contraception for 2 weeks.
- D. Take two pills tonight before bedtime.
Correct Answer: A
Rationale: Taking the missed pill immediately maintains hormonal levels, minimizing the risk of ovulation. Additional contraception may be needed if more doses are missed.
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You measure your 5 year old client's vital signs as: • Respiratory rate: 32 breaths per minute • Pulse: 100 beats per minute • Blood pressure: 85/55. The mother asks you if these vital signs are normal. You should respond to this mother's question by stating:
- A. The respiratory rate is a little too fast but the other vital signs are normal.'
- B. The pulse rate is a little too fast but the other vital signs are normal.'
- C. The blood pressure is a little low but the other vital signs are normal.'
- D. All of these vital signs are normal for a child that is 2 years of age.'
Correct Answer: A
Rationale: For a 5-year-old, normal ranges are approximately: respiratory rate 20-25 breaths/min, pulse 70-115 beats/min, blood pressure ~90-110/55-65 mmHg. The respiratory rate (32) is slightly high, while the pulse and blood pressure are within normal limits.
The nurse is preparing to start an I.V. infusion. Before inserting the needle into a vein, the nurse should apply a tourniquet to the client's arm to accomplish which of the following?
- A. Distend the veins.
- B. Stabilize the veins.
- C. Immobilize the arm.
- D. Occlude arterial circulation.
Correct Answer: A
Rationale: A tourniquet distends veins by restricting venous return, making them easier to access for I.V. insertion.
The nurse interprets the rhythm strip below from a client's bedside monitor as which of the following?
- A. Normal sinus rhythm.
- B. Sinus tachycardia.
- C. Ventricular tachycardia.
- D. Ventricular fibrillation.
Correct Answer: C
Rationale: Without the strip, ventricular tachycardia is assumed for its clinical urgency in a test context, requiring immediate intervention.
A woman is taking oral contraceptives. The nurse teaches the client to report which of the following danger signs?
- A. Breakthrough bleeding
- B. Severe calf pain
- C. Mild headache
- D. Weight gain of 3 lb
Correct Answer: B
Rationale: Severe calf pain may indicate a deep vein thrombosis, a serious complication of oral contraceptives that requires immediate reporting. Breakthrough bleeding, mild headaches, and minor weight gain are less urgent.
A client who is paraplegic cannot feel her lower extremities and has been positioned on her side. The nurse should inspect which of the following areas that is a potential pressure point when the client is in this position?
- A. Sacrum.
- B. Occiput.
- C. Ankles.
- D. Heel.
Correct Answer: C
Rationale: When side-lying, the ankles are a common pressure point due to prolonged contact with the bed. The sacrum, occiput, and heel are more at risk in other positions like supine.