Nokea
A pregnant client is keeping a 'kick count' log during the last trimester. Which of the following may indicate fetal distress?
- A. Fewer than 5 movements within 2 hours
- B. Fewer than 5 movements within 1 hour
- C. Fewer than 10 movements within 2 hours
- D. Fewer than 10 movements within 1 hour
Correct Answer: C
Rationale: Fewer than 10 movements in 2 hours (C) suggests fetal distress, as normal is >10 movements in 2 hours. Other options (A, B, D) set incorrect thresholds.
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The nurse is caring for a client receiving supplemental oxygen. The effectiveness of the oxygen therapy is best determined by:
- A. The rate of respirations
- B. The absence of cyanosis
- C. Arterial blood gases
- D. The level of consciousness
Correct Answer: C
Rationale: Arterial blood gases provide a direct measure of oxygenation and are the most accurate way to evaluate the effectiveness of oxygen therapy.
The doctor has prescribed a diet high in vitamin B12 for a client with pernicious anemia. Which foods are good sources of B12?
- A. Meat, eggs, dairy products
- B. Peanut butter, raisins, molasses
- C. Broccoli, cauliflower, cabbage
- D. Shrimp, legumes, bran cereals
Correct Answer: A
Rationale: Vitamin B12 is found in animal products like meat, eggs, and dairy, essential for treating pernicious anemia due to impaired B12 absorption.
A client is being treated for irritable bowel syndrome (IBS). The nurse knows that the involvement of nursing, pharmacy, gastroenterology, and nutritional services is an example of which of the following approaches?
- A. continuity of care
- B. multidisciplinary
- C. managed care
- D. case management
Correct Answer: B
Rationale: A multidisciplinary approach involves multiple specialties (nursing, pharmacy, gastroenterology, nutrition) collaborating to manage IBS.
The nurse is conducting a physical examination of a client's abdomen. Place the examination techniques listed below (Roman numerals) in the correct sequence, from first to last.
- A. Percussion
- B. Palpation
- C. Inspection
- D. Auscultation
Correct Answer: C,D,A,B
Rationale: Abdominal exam sequence: Inspection (III) first, then auscultation (IV) before percussion (I) and palpation (II) to avoid altering bowel sounds.
A non-immune nurse should not be assigned a client who has which of the vaccine-preventable airborne diseases? Select all that apply.
- A. tuberculosis
- B. influenza
- C. smallpox
- D. pertussis
Correct Answer: A,C
Rationale: Tuberculosis and smallpox are airborne, vaccine-preventable diseases posing risks to non-immune nurses. Influenza and pertussis are primarily droplet-transmitted.