Nokea
A pregnant client experiences spontaneous rupture of membranes. The first nursing action is to:
- A. Assess the client's respirations
- B. Notify the physician
- C. Auscultate fetal heart rate
- D. Transfer to delivery suite
Correct Answer: C
Rationale: Auscultating fetal heart rate is critical after membrane rupture to assess for cord prolapse, a potential complication.
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The client is admitted with a diagnosis of gastroenteritis. Which precaution should the nurse implement?
- A. Standard precautions
- B. Contact precautions
- C. Droplet precautions
- D. Airborne precautions
Correct Answer: B
Rationale: Gastroenteritis is often caused by pathogens like norovirus, requiring contact precautions to prevent fecal-oral transmission. Standard precautions are insufficient, and droplet or airborne are not indicated.
The best size cathlon for administration of a blood transfusion to a six-year-old is:
- A. 18 gauge
- B. 19 gauge
- C. 22 gauge
- D. 20 gauge
Correct Answer: D
Rationale: A 20-gauge catheter is appropriate for blood transfusions in a six-year-old balancing adequate flow rate and minimal vessel trauma. Smaller gauges (22) may be too small and larger gauges (18 19) are more invasive than necessary.
A client was admitted to the hospital after falling in her home. At the time of admission, her blood alcohol level was 0.27 mg%. Her family indicates that she has been drinking a fifth of vodka a day for the past 9 months. She had her last drink 30 minutes prior to admission. Alcohol withdrawal symptoms would most likely be exhibited by her:
- A. Two to 4 hours after the last drink
- B. Six to 8 hours after the last drink
- C. Immediately on admission
- D. Twenty-four hours after the last drink
Correct Answer: B
Rationale: This answer is incorrect. Alcohol withdrawal usually begins approximately 6-8 hours after the last drink. This answer is correct. It takes approximately 6-8 hours for metabolism of alcohol. This answer is incorrect. The alcohol is still in the system, as indicated by the high blood alcohol level. This answer is incorrect. Symptoms of alcohol withdrawal usually begin within 6-8 hours of the last drink.
Which behaviors are expected to be observed in the 18-month old?
- A. Has a vocabulary of 900 words
- B. Removes clothes
- C. Points to at least one named body part
- D. Asks many questions
- E. Can kick a ball forward
Correct Answer: B, C, E
Rationale: At 18 months, children remove clothes (B), point to body parts (C), and kick balls (E). Vocabulary is ~20-50 words (A), and questioning (D) emerges later (~2-3 years).
Azulfidine (Sulfasalazine) may be ordered for a client who has ulcerative colitis. Which of the following is a nursing implication for this drug?
- A. Limit fluids to 500 mL/day.
- B. Administer 2 hours before meals.
- C. Observe for skin rash and diarrhea.
- D. Monitor blood pressure, pulse.
Correct Answer: C
Rationale: Sulfasalazine commonly causes skin rash and diarrhea, which should be monitored. The other options are not relevant nursing implications.