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A nurse is obtaining a 2-hr postprandial blood glucose from a client. Which of the following actions should the nurse take?
- A. Puncture the finger while still damp with antiseptic solution.
- B. Smear the blood onto the reagent strip.
- C. Hold the finger above the heart prior to puncture.
- D. Select the lateral side of the finger for puncture.
Correct Answer: D
Rationale: The correct answer is D: Select the lateral side of the finger for puncture. This is because the lateral side of the finger has fewer nerve endings, which can reduce pain for the client. Puncturing the finger while still damp with antiseptic solution (A) can dilute the blood sample and affect accuracy. Smearing the blood onto the reagent strip (B) can lead to inaccurate results. Holding the finger above the heart prior to puncture (C) can increase blood flow and dilute the sample. In summary, selecting the lateral side of the finger for puncture is the best option to minimize pain and ensure an accurate blood glucose reading.
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A nurse is assisting the provider to administer a dinoprostone insert to induce labor for a client. Which of the following actions should the nurse take?
- A. Allow the medication to reach room temperature prior to administration.
- B. Place the client in a semi-Fowler’s position for 1 hr after administration.
- C. Instruct the client to avoid urinary elimination until after administration.
- D. Verify that informed consent is obtained prior to administration.
Correct Answer: D
Rationale: The correct answer is D: Verify that informed consent is obtained prior to administration. This step is crucial to ensure the client understands the risks and benefits of the procedure. It promotes client autonomy and helps prevent legal issues.
A: Allowing the medication to reach room temperature is not a necessary step for administering dinoprostone insert.
B: Placing the client in a semi-Fowler's position is not indicated after administering dinoprostone insert.
C: Instructing the client to avoid urinary elimination is not necessary and could be harmful to the client.
E, F, G: No other options are provided, but they would likely be incorrect as well.
A nurse is providing teaching about increasing dietary fiber to an antepartum client who reports constipation. Which of the following food selections has the highest fiber content per cup?
- A. Oatmeal
- B. Cabbage
- C. Asparagus
- D. Lentils
Correct Answer: D
Rationale: The correct answer is D: Lentils. Lentils have a high fiber content, providing about 15.6 grams of fiber per cooked cup. This high fiber content can help alleviate constipation in the antepartum client. Oatmeal, cabbage, and asparagus have lower fiber content compared to lentils. Oatmeal contains around 4 grams of fiber per cup, cabbage has about 2 grams per cup, and asparagus provides about 3 grams of fiber per cup. Therefore, lentils offer the highest fiber content per cup among the options provided, making them the most suitable choice to address constipation in the antepartum client.
Which of the following nursing actions should the nurse plan to take? For each potential nursing action, click to specify it the intervention is indicated or contraindicated for the client.
- A. Insert a large bore intravenous catheter.
- B. Assess cervical dilation.
- C. Weigh perineal pads.
- D. Administer methotrexate.
Correct Answer: A, C
Rationale: [, (0, 0, 0), (1, 0, 0), (0, 0, 1)]
Correct Answer: A, C
Rationale:
A: Inserting a large bore intravenous catheter is indicated for quick and efficient fluid administration in emergencies or critical conditions.
C: Weighing perineal pads helps monitor postpartum hemorrhage accurately by assessing the amount of blood loss.
Assessing cervical dilation (B) is not indicated unless specified for a specific medical condition. Administering methotrexate (D) is contraindicated in pregnancy and certain medical conditions.
A nurse is assessing a client who is at 6 weeks of gestation and adheres to a vegan diet. Which of the following questions should the nurse ask to assess the client’s dietary intake?
- A. How much protein do you eat in a day?
- B. Are you taking a Vitamin C supplement?
- C. Have you considered eating shellfish?
- D. When was the last time you ate meat?
Correct Answer: A
Rationale: The correct answer is A: How much protein do you eat in a day? This question is important because a vegan diet may lack sufficient protein, which is crucial for fetal development. Protein intake is a key concern for pregnant vegans to ensure adequate nutrition for both the mother and the developing fetus.
Choice B is incorrect because Vitamin C deficiency is not typically a major concern for pregnant vegans. Choice C is incorrect as shellfish is not suitable for a vegan diet. Choice D is incorrect as asking about eating meat is not relevant to someone following a vegan diet.
A nurse is assessing a newborn following a forceps-assisted birth. Which of the following clinical manifestations should the nurse identify as a complication of this birth method?
- A. Polycythemia
- B. Hypoglycemia
- C. Bronchopulmonary dysplasia
- D. Facial palsy
Correct Answer: D
Rationale: The correct answer is D: Facial palsy. Forceps-assisted birth can put pressure on the baby's face, potentially leading to facial nerve injury and resulting in facial palsy. This occurs due to the compression of the facial nerve during delivery. Other choices are incorrect: A - Polycythemia is not directly related to forceps-assisted birth. B - Hypoglycemia is more commonly associated with maternal diabetes or prematurity. C - Bronchopulmonary dysplasia is a lung condition primarily seen in premature infants requiring mechanical ventilation or oxygen therapy. In summary, facial palsy is the most likely complication following a forceps-assisted birth due to the pressure exerted on the baby's face during delivery.