Nokea
A nurse is supervising a student in preparing the physical environment for an interview with a client. Which action by the student is correct?
- A. Setting the room temperature at a comfortable level
- B. Placing a chair for the client across from the nurse's desk
- C. Providing seating for the client so that the client faces a strong light
- D. Setting up seating so that the client and nurse are not at eye level
Correct Answer: A
Rationale: When preparing the physical environment for an interview with a client, it is crucial to ensure the client's comfort. Setting the room temperature at a comfortable level is essential for the client's well-being. Additionally, providing privacy, sufficient lighting, and removing distractions are crucial factors. It is recommended to maintain a distance of around 4 to 5 feet between the client and the nurse. Seating should be arranged so that the client and nurse are at eye level to facilitate effective communication and prevent barriers. Placing a chair across from the nurse's desk may create a physical barrier, positioning the client to face a strong light can be uncomfortable and distracting, and setting up seating so that the client and nurse are not at eye level may impede effective communication.
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The chemotherapeutic DNA alkylating agents such as nitrogen mustards are effective because they:
- A. cross-link DNA strands with covalent bonds between alkyl groups on the drug and guanine bases on DNA.
- B. have few, if any, side effects.
- C. are used to treat multiple types of cancer.
- D. are cell-cycle-specific agents.
Correct Answer: A
Rationale: Alkylating agents are highly reactive chemicals that introduce alkyl radicals into biologically active molecules and thereby prevent their proper functioning, replication, and transcription. Choice 2 is incorrect because alkylating agents have numerous side effects including alopecia, nausea, vomiting, and myelosuppression. Choice 3 is incorrect because nitrogen mustards have a broad spectrum of activity against chronic lymphocytic leukemia, non-Hodgkin's lymphoma, and breast and ovarian cancer, but they are effective chemotherapeutic agents because of DNA crosslinkage. Choice 4 is incorrect because alkylating agents are non-cell-cycle-specific agents.
A woman is receiving oxytocin to induce labor. Which action should the nurse take first upon noting the presence of late decelerations on the fetal heart rate (FHR) monitor?
- A. Notifying the healthcare provider
- B. Stopping the oxytocin infusion
- C. Checking the woman's blood pressure and pulse
- D. Increasing the intravenous (IV) rate of the nonadditive solution
Correct Answer: B
Rationale: When late decelerations are noted on the fetal heart rate (FHR) monitor during oxytocin infusion, it indicates decreased oxygenation to the fetus. The immediate action the nurse should take is to stop the oxytocin infusion. This helps reduce uterine activity, increase fetal oxygenation, and prevent further stress on the fetus. Stopping the oxytocin infusion is crucial to address the underlying issue causing the late decelerations. Checking the woman's blood pressure and pulse, increasing the IV rate of the nonadditive solution, or notifying the healthcare provider can be important actions but are secondary to stopping the oxytocin infusion in this scenario.
A preschooler has successfully completed the test item 'counts 5 blocks' on the Denver II test. This pass is evidence of which of the following developmental concepts?
- A. centration
- B. causality
- C. nonreversibility
- D. conservation
Correct Answer: D
Rationale: The ability of a preschooler to move five blocks to a piece of paper and state there are five blocks on the paper is evidence that the preschooler has the ability of conservation. This concept refers to the fact that the quantity of something doesn't change just because the shape, contour, and so on has changed. Five blocks are still five blocks, whether they are lying beside the paper, stacked on the paper, or moved to the paper. Centration is the ability to concentrate on one feature of a situation while neglecting all other aspects. Causality is based on the sequence of events, one event ordinarily following another. Non-reversibility refers to the inability of preschoolers to reverse their operations. They are only able to think forward, not retrace or reverse their thought processes.
A woman who delivered a healthy newborn 6 hours earlier complains of discomfort at the episiotomy site. Which action by the nurse is the most appropriate?
- A. Administering an intravenous (IV) opioid analgesic
- B. Assisting the woman in taking a warm sitz bath
- C. Applying an ice pack to the perineum
- D. Contacting the registered nurse
Correct Answer: C
Rationale: Applying an ice pack to the perineum is the most appropriate action in this scenario. Ice causes vasoconstriction, providing relief by numbing the area and preventing edema. It is typically used within the first 12 to 24 hours after birth. Assisting the woman in taking a warm sitz bath is more suitable after 24 hours as warm water can be soothing. Administering an IV opioid analgesic is excessive; an anesthetic spray is more appropriate for surface discomfort. Contacting the registered nurse is unnecessary as applying an ice pack is within the nurse's scope and can effectively address the discomfort without escalation.
A client describes her cervical mucus as clear, thin, and elastic. Upon examination, the nurse demonstrates that the cervical mucus can be stretched 8-10 cm. The nurse correctly documents the finding as:
- A. Ferning capacity
- B. Lack of ferning
- C. Spinnbarkheit
- D. Inhospitable
Correct Answer: C
Rationale: Spinnbarkheit is the term for stretchy, elastic cervical mucus at ovulation, indicating fertility. Ferning requires microscopic examination, and inhospitable mucus inhibits sperm motility.