Nokea
A nurse is assisting with monitoring a client who is at 40 weeks of gestation and is in active labor. The nurse recognizes late decelerations on the fetal monitor tracing. Which of the following actions should the nurse take?
- A. Apply oxygen at 10 L/min via face mask
- B. Position the client on their side
- C. Call for a Cesarean delivery
- D. Administer oxytocin
Correct Answer: B
Rationale: Late decelerations indicate uteroplacental insufficiency, and the priority nursing action is to improve placental perfusion. Positioning the client on their side, particularly the left side, can enhance blood flow to the placenta and fetus by reducing pressure on the vena cava and increasing cardiac output. Applying oxygen, although helpful, is not the initial priority in this situation. Calling for a Cesarean delivery is not warranted unless other interventions fail to correct the late decelerations. Administering oxytocin can worsen the condition by increasing uterine contractions, exacerbating fetal distress.
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A healthcare provider is reviewing the medical record of a client who is scheduled for surgery. Which of the following findings should the provider report?
- A. White blood cell count of 8,000/mm³
- B. Potassium level of 4.0 mEq/L
- C. Creatinine level of 1.0 mg/dL
- D. Hemoglobin level of 12 g/dL
Correct Answer: C
Rationale: An elevated creatinine level indicates impaired kidney function, which may affect the client's ability to undergo surgery. The other laboratory values (white blood cell count, potassium level, and hemoglobin level) are within normal ranges and do not directly impact the client's readiness for surgery.
A nurse is teaching a client who has chronic obstructive pulmonary disease (COPD) about breathing exercises. Which of the following instructions should the nurse include?
- A. Use abdominal breathing during physical activity
- B. Inhale quickly and deeply through the nose
- C. Use pursed-lip breathing during physical activity
- D. Breathe quickly and deeply during exercise
Correct Answer: C
Rationale: The correct answer is C: 'Use pursed-lip breathing during physical activity.' Pursed-lip breathing is a beneficial technique for clients with COPD as it helps improve airflow by keeping the airways open longer. Choice A is incorrect as abdominal breathing may not be as effective in COPD as pursed-lip breathing. Choice B, inhaling quickly and deeply through the nose, is not recommended as it can lead to hyperventilation. Choice D, breathing quickly and deeply during exercise, is also not suitable for clients with COPD as it can cause increased shortness of breath.
Which assessment finding is expected with myxedema?
- A. Increased pulse rate
- B. Decreased temperature
- C. Fine tremors
- D. Weight loss
Correct Answer: B
Rationale: Myxedema is characterized by a decreased metabolic rate, leading to manifestations such as decreased temperature. Therefore, the correct assessment finding expected with myxedema is a decreased temperature. Choices A, C, and D are incorrect because myxedema typically presents with a decreased pulse rate, not an increased pulse rate, absence of fine tremors (which are more common in hyperthyroidism), and weight gain rather than weight loss.
A client is postoperative following a hip replacement. Which of the following interventions should the nurse implement to prevent dislocation of the prosthesis?
- A. Encourage the client to bend at the waist
- B. Maintain the client in a high-Fowler's position
- C. Place a pillow between the client's legs
- D. Avoid placing a pillow under the client's knees
Correct Answer: C
Rationale: Placing a pillow between the client's legs is beneficial after hip replacement surgery to maintain proper alignment and prevent dislocation of the prosthesis. This position helps keep the hip in a neutral position, reducing the risk of dislocation. Encouraging the client to bend at the waist (Choice A) can increase the risk of hip dislocation. Maintaining the client in a high-Fowler's position (Choice B) and avoiding placing a pillow under the client's knees (Choice D) do not directly address the need to maintain proper alignment of the hip joint to prevent dislocation.
What are the early signs of hypoglycemia in a diabetic patient?
- A. Sweating and trembling
- B. Confusion and irritability
- C. Dizziness and increased heart rate
- D. Nausea and vomiting
Correct Answer: A
Rationale: The correct answer is A: 'Sweating and trembling.' These are classic early signs of hypoglycemia in a diabetic patient. Sweating occurs due to the activation of the sympathetic nervous system in response to low blood sugar levels, while trembling is a result of the body's attempt to increase muscle activity to raise blood sugar levels. Confusion and irritability (Choice B) are more advanced signs of hypoglycemia that occur if the condition is not treated promptly. Dizziness and increased heart rate (Choice C) can also occur but are not as specific and early as sweating and trembling. Nausea and vomiting (Choice D) are more commonly associated with other conditions or severe hypoglycemia, rather than being early signs.