Nokea
A nurse hears a co-worker state that anybody could be a nurse since it is so automated with infusion devices and electronic monitoring; technology is doing the work. What is the nurse’s best response?
- A. Technology use has to be combined with nursing judgment.
- B. The focus of effective nursing care is technology.
- C. If it’s so easy, why don’t you do it?
- D. That is true in the 20th century.
Correct Answer: A
Rationale: In many ways, technology makes work easier, but it does not replace nursing judgment. Technology does not replace your critical eye and clinical judgment. Most importantly, it is essential to remember that the focus of nursing care is not the machine or the technology; it is the patient.
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In which type of health care facility does the nurse want to work if applying for a position with a home care organization that specializes in spinal cord injury?
- A. Secondary acute
- B. Continuing
- C. Restorative
- D. Tertiary
Correct Answer: C
Rationale: Patients recovering from an acute or chronic illness or disability often require additional services (restorative care) to return to their previous level of function or reach a new level of function limited by their illness or disability.
The nurse has admitted a client who is 30 weeks gestation with suspected intrauterine growth restriction. The physician has ordered a Doppler blood flow study. What does the nurse suspect if the results show an S/D ratio above the 95th percentile for the gestational age, a ratio above 3, or end-diastolic blood flow that is absent or reversed?
- A. Decreased blood pressure
- B. Placental insufficiency
- C. Increased amniotic fluid
- D. Decreased fetal movement
Correct Answer: B
Rationale: The correct answer is B: Placental insufficiency. An elevated S/D ratio (>95th percentile for gestational age or >3) and absent/reversed end-diastolic blood flow on Doppler study indicate impaired placental blood flow, leading to decreased oxygen and nutrient delivery to the fetus. This can result in intrauterine growth restriction (IUGR) and compromise fetal well-being. Decreased blood pressure (A) is not directly related to these Doppler findings. Increased amniotic fluid (C) is more commonly associated with conditions like fetal anomalies or maternal diabetes. Decreased fetal movement (D) may be a sign of fetal distress but is not specifically indicated by Doppler findings in IUGR.
A client who had a vaginal delivery 2 hours earlier has just been transferred to the postpartum unit from labor and delivery. Which of the following nursing care goals is of highest priority?
- A. The client will breastfeed her baby every 2 hours.
- B. The client will consume a nutritious diet.
- C. The client will have a moderate lochial flow.
- D. The client will ambulate in the hallways every shift.
Correct Answer: C
Rationale: Ensuring the client has a moderate lochial flow is a priority to monitor for postpartum hemorrhage.
A client complaining of frequency, urgency, and burning on urination is seen by her health care practitioner. Which of the following factors in the client's history places her at risk for these complaints?
- A. The client urinates immediately after every sexual encounter.
- B. The client uses the diaphragm as a family planning method.
- C. The client wipes from front to back after every toileting.
- D. The client changes her peripads every two hours during her menses.
Correct Answer: B
Rationale: The use of a diaphragm can increase the risk of urinary tract infections due to pressure on the urethra.
Which laboratory is important to know when a client is having an amniocentesis?
- A. Blood type
- B. CBC
- C. Rh
- D. PT and PTT
Correct Answer: C
Rationale: Step-by-step rationale:
1. Rh factor is crucial to know to prevent Rh incompatibility issues during pregnancy.
2. Amniocentesis can pose a risk for Rh sensitization in Rh-negative mothers.
3. Knowing the Rh status helps determine if Rhogam (anti-D) is needed after amniocentesis.
4. Blood type (A) and CBC (B) are important but not directly relevant to amniocentesis.
5. PT and PTT (D) are coagulation tests, typically not required for routine amniocentesis.