Nokea
A nurse is participating in an obstetrical emergency simulation in which the health care provider announces shoulder dystocia. Which of the following interventions should the assisting nurse implement?
- A. Assist maternal pushing efforts by applying fundal pressure during each contraction
- B. Document the time the fetal head was born
- C. Flex the client's legs back against the abdomen and apply downward pressure above the symphysis pubis
- D. Prepare for a forceps-assisted birth
- E. Request additional assistance from other nurses immediately
Correct Answer: C,E
Rationale: Shoulder dystocia requires urgent interventions like the McRoberts maneuver (flexing legs back, C) and suprapubic pressure (C) to dislodge the fetal shoulder. Additional assistance (E) is critical. Fundal pressure (A) can worsen impaction. Documentation (B) is secondary to immediate action. Forceps (D) are not typically used for shoulder dystocia.
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A nurse on an orthopedic unit is caring for four clients with a casted extremity. Which client does the nurse prioritize to see first?
- A. Client reporting a tingling sensation
- B. Client reporting itching under the cast
- C. Client reporting pain of 5/10 on movement
- D. Client reporting throbbing on dependent positioning
Correct Answer: A
Rationale: Tingling (A) suggests neurovascular compromise, requiring urgent assessment. Itching (B), moderate pain (C), and throbbing (D) are less critical.
The nurse is assessing a client at 11 weeks gestation. The first day of the client's last menstrual period was September 7. Which of the following findings should the nurse expect to obtain?
- A. reports feeling fetal movement
- B. reports increased urinary frequency
- C. fundal height of 24 cm above the symphysis pubis
- D. estimated delivery date of June 14 using the Naegele rule
- E. fetal heart tones detectable via Doppler ultrasound device
Correct Answer: B,D,E
Rationale: At 11 weeks, increased urinary frequency (B) is expected due to hormonal changes. The Naegele rule (LMP + 1 year - 3 months + 7 days) gives June 14 (D). Fetal heart tones are detectable by Doppler (E). Fetal movement (A) is felt later (16-20 weeks), and fundal height of 24 cm (C) occurs around 24 weeks.
There has been a large-scale community disaster and clients must be roomed together at the hospital. Who are appropriate roommates in light of infection risk principles?
- A. A client diagnosed with varicella and a client with pertussis
- B. A client placed in an airborne infection isolation room (AIIR) and a client with heart failure
- C. A client receiving chemotherapy and a client with chronic obstructive pulmonary disease (COPD) coughing yellow sputum
- D. A client with pelvic inflammatory disease (PID) and a client with coffee ground emesis
- E. Two clients diagnosed with tuberculosis
Correct Answer: D
Rationale: PID and coffee ground emesis (D) are non-infectious, making them suitable roommates. Varicella, pertussis, TB (A, E), and COPD with sputum (C) pose infection risks. AIIR (B) is for airborne infections, incompatible with heart failure.
The nurse is caring for a client who is receiving peritoneal dialysis and is reporting chills and abdominal discomfort. The nurse notes rebound tenderness with palpation. Which of the following actions would be a priority for the nurse to take?
- A. Discontinue the exchange and collect a peritoneal fluid specimen for culture and sensitivity.
- B. Warm the remaining dialysate fluid and increase the dwell time of the exchange.
- C. Administer a dose of oxycodone prescribed PRN for the client.
- D. Place the client in the high-Fowler position in bed.
Correct Answer: A
Rationale: Chills, discomfort, and rebound tenderness suggest peritonitis, requiring fluid culture (A). Warming dialysate (B), pain medication (C), and positioning (D) do not address the infection.
The nurse cares for a hospitalized client with malnutrition related to anorexia nervosa. Which of the following actions are appropriate in the care of this client?
- A. Allow the client to continue to exercise per usual routine
- B. Assist the client in reflecting on triggers of disordered eating
- C. Document the client's daily intake of calories and protein
- D. Remain with the client for the duration of each meal
- E. Weigh the client each morning prior to any oral intake
Correct Answer: B,C,D,E
Rationale: Reflecting on triggers (B), documenting intake (C), staying during meals (D), and daily weighing (E) support recovery. Exercise (A) should be limited to prevent calorie expenditure.