Nokea
A nurse is caring for a person who is blind. What intervention could the nurse implement to deliver culturally responsive care?
- A. Ask family members to leave the room for the discussion of care.
- B. Be aware of how the person is addressed.
- C. Introduce herself with her name and credentials upon entering the room.
- D. Leave education material in Braille on the table across the room from the bed.
Correct Answer: C
Rationale: Introducing oneself clearly helps build trust and ensures the patient knows who is providing care.
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A nurse is providing discharge teaching to a client who is 3 days postoperative following a cesarean birth. Which of the following client statements should indicate to the nurse the
- A. "I am likely to have a fever during the first week I am home."
- B. "I will resume taking my prenatal vitamins."
- C. "I will call my provider if I have discharge from my incision."
- D. "I should not have unrelieved pain in my abdomen."
Correct Answer: C
Rationale: The correct statement that should indicate to the nurse that the client understands the discharge teaching is "I will call my provider if I have discharge from my incision." This response demonstrates the client's understanding of the importance of monitoring the incision site for signs of infection or complications. It shows that the client is aware of the potential risks postoperatively and is prepared to take necessary action by notifying the healthcare provider if any issues arise. Monitoring incision discharge is essential to prevent infection and ensure proper healing after a cesarean birth.
What response should the nurse make first to a young woman who showered after a sexual assault?
- A. The evidence kit may still reveal important information.
- B. It was important for you to do that for yourself.
- C. Have you washed your clothes? If not, we might be able to obtain evidence from them.
- D. Do you remember what happened? If not, someone may have put a drug in your drink.
Correct Answer: A
Rationale: Preserving evidence is critical for legal proceedings.
Which assessment finding indicates a complication in a client attempting a VBAC?
- A. Complaint of pain between the scapula (could be uterine
- C. Contraction every 3 minutes lasting 70 seconds
- D. Pain level 6 at acme of
Correct Answer: C
Rationale: A client attempting a Vaginal Birth After Cesarean (VBAC) is at higher risk for uterine rupture. A concerning assessment finding in this scenario would be the occurrence of contractions every 3 minutes that are lasting 70 seconds. This pattern of contractions could potentially indicate uterine hyperstimulation, which increases the risk of uterine rupture. It is essential to closely monitor these contractions and address any signs of distress or complications promptly to ensure the safety of both the mother and the baby.
Which of the following is an example of healthy grieving?
- A. The mother exhibits an absence of crying or expression of feelings.
- B. The parents do not mention the baby in conversation with family members.
- C. The mother asks that the baby be taken away from the delivery area quickly.
- D. While holding the baby, the mother says to her husband, "He has your eyes and nose."
Correct Answer: D
Rationale: Option D, while holding the baby, the mother saying to her husband, "He has your eyes and nose," is an example of healthy grieving. In this scenario, the mother is acknowledging the baby, expressing emotions, and involving her partner in the process. Verbalizing thoughts and emotions, as well as creating meaningful connections with relevant support persons, are important aspects of healthy grieving. Sharing memories and recognizing the physical similarities between the baby and family members can be therapeutic in the grieving process.
A nurse is caring for a client following an amniocentesis. The nurse should observe the client for which of the following complications?
- A. Hyperemesis
- B. Proteinuria
- C. Hypoxia
- D. Hemorrhage
Correct Answer: D
Rationale: Following an amniocentesis, the nurse should observe the client for the potential complication of hemorrhage. Amniocentesis is a procedure where a small amount of amniotic fluid is extracted from the amniotic sac surrounding the fetus for various diagnostic purposes. The risk of hemorrhage is associated with this invasive procedure due to the possibility of damaging blood vessels within the uterus during the insertion of the needle. It is important for the nurse to closely monitor the client for any signs of bleeding, such as vaginal bleeding, abdominal pain, or signs of shock, and report any concerns promptly to the healthcare provider for further evaluation and management.