Nokea
A nurse is preparing to auscultate a fetal heart rate (FHR). The nurse performs the Leopold maneuvers to determine the position of the fetus and then places the fetoscope over which part of the fetus?
- A. Back of the fetus
- B. Carotid artery in the neck of the fetus
- C. Brachial area of one extremity of the fetus
- D. Chest of the fetus
Correct Answer: A
Rationale: The nurse would use the Leopold maneuvers to identify the position of the fetus and determine the location of the fetal back. The fetal heart rate (FHR) is most easily heard through the fetal back because it usually lies closest to the surface of the maternal abdomen. Auscultation of the FHR over the chest, carotid artery, or brachial area is not possible due to the fetal position within the maternal abdomen. Placing the fetoscope over the carotid artery or brachial area would not yield the fetal heart rate, and the chest area is not typically used for auscultating the FHR.
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A nurse auscultating the fetal heart rate (FHR) of a pregnant client in the first trimester of pregnancy notes that the FHR is 160 beats/min. With this information, what should be the nurse's next action?
- A. Notify the healthcare provider of the finding.
- B. Document the findings.
- C. Tell the client that the FHR is faster than normal but that it is nothing to be concerned about at this time.
- D. Wait 15 minutes and then recheck the FHR.
Correct Answer: B
Rationale: An FHR of 160 beats/min in the first trimester of pregnancy is within the normal range, which is generally 120 to 160 beats/min. The appropriate action for the nurse in this situation is to document the findings. There is no need to notify the healthcare provider as this is a normal finding. Informing the client that the FHR is faster than normal may cause unnecessary anxiety, as it falls within the expected range. Waiting to recheck the FHR is not necessary since the rate is already within the normal range.
A nurse is assisting with data collection regarding skin and peripheral vascular findings on a client in later adulthood. Which observation would the nurse expect to note as an age-related finding?
- A. Thin, ridged toenails
- B. Thick skin on the lower legs
- C. Loss of hair on the lower legs
- D. Bounding dorsalis pedis pulse
Correct Answer: C
Rationale: In later adulthood, age-related findings include trophic changes associated with arterial insufficiency, such as thin, shiny skin; thin, ridged toenails; and loss of hair on the lower legs. These changes occur normally with aging. Thick skin on the lower legs would not be an expected age-related finding as it typically indicates chronic venous insufficiency. A bounding dorsalis pedis pulse is not typical in later adulthood and may indicate arterial insufficiency, which is not an age-related finding.
Which of the following solutions is routinely used to flush an IV device before and after the administration of blood to a client?
- A. 0.9% sodium chloride
- B. 5% dextrose in water solution
- C. Sterile water
- D. Heparin sodium
Correct Answer: A
Rationale: The correct answer is 0.9% sodium chloride. Normal saline is 0.9% sodium chloride, which has the same osmolarity as blood and does not cause cell lysis. Choices 2 and 3, 5% dextrose in water solution and sterile water, are hypotonic solutions that can lead to cell lysis. Choice 4, heparin sodium, is an anticoagulant and is not used for flushing IV devices before and after blood administration.
A nurse is participating in a planning conference to improve dietary measures for an older client experiencing dysphagia. Which action should the nurse suggest including in the plan of care?
- A. Monitoring the client during meals to ensure that food is swallowed
- B. Encouraging the client to feed themselves
- C. Consulting with the physician regarding feeding through an enteral tube
- D. Ensuring that the diet consists of both solids and liquids
Correct Answer: A
Rationale: For clients with dysphagia, ensuring successful swallowing of food and preventing aspiration is crucial. Therefore, the nurse should suggest monitoring the client closely during meals to provide assistance as needed. While a balanced diet is important, special considerations like adding thickeners for liquids may be required for dysphagia clients. Consulting with a physician about enteral tube feeding should be based on the severity of the condition, making it a premature step without clear indications. Encouraging self-feeding may not be appropriate for dysphagia clients who require close monitoring and assistance, as it could increase the risk of complications.
When a client describes their family as having multiple wives, all of whom are sisters, married to one man, the nurse documents the family structure as?
- A. polyandry
- B. sororal
- C. nonsororal
- D. soronal
Correct Answer: D
Rationale: The correct answer is 'soronal.' The practice of polygamy refers to having multiple wives or husbands. When there are multiple wives who are sisters, the polygamy is designated as sororal. Polyandry refers to multiple husbands, which is rare. Nonsororal polygamy is when the wives are not sisters. Sororate polygamy specifies that a husband must marry his wife’s sister if she dies. Therefore, in this scenario, the family structure described by the client fits the definition of soronal polygamy.