Nokea
A pregnant diabetic client, who is 37 weeks gestation, is scheduled for an amniocentesis. The client asks the nurse the purpose of the test. The nurse should explain that the primary reason for performing an amniocentesis is:
- A. To determine the effect of the diabetes on the fetus
- B. To estimate the skeletal age of the fetus
- C. To determine the fetal lung maturity
- D. To obtain information about aberrant fetal genes
Correct Answer: C
Rationale: At 37 weeks, amniocentesis primarily assesses fetal lung maturity via lecithin/sphingomyelin ratio, critical for delivery planning. Diabetes effects , skeletal age , and genetic issues are less common indications.
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A newborn weighed 7 pounds 2 ounces at birth. The nurse assesses the newborn at home 2 days later and finds the weight to be 6 pounds 7 ounces. What should the nurse tell the parents about this weight loss?
- A. The newborn needs additional assessments
- B. The mother should breast feed more often
- C. A change to formula is indicated
- D. The loss is within normal limits
Correct Answer: D
Rationale: The loss is within normal limits. A newborn is expected to lose 5-10% of the birth weight in the first few days post-partum because of changes in elimination and feeding.
The nurse is teaching unlicensed personnel about preventing the spread of disease in the health care environment. The nurse knows that the personnel understand when they state that which is the most important way to prevent the spread of disease?
- A. Isolating infected clients
- B. Consistently washing hands
- C. Wearing a gown when there is a question of a client with a questionable disease
- D. Wearing gloves whenever giving care
Correct Answer: B
Rationale: Hand washing is the most effective way to prevent disease transmission, breaking the chain of infection in healthcare settings.
Prochlorperazine maleate (Compazine) 10 mg IM has been ordered for a client.
- A. What should the nurse do before administering prochlorperazine 10 mg IM and Stadol 2 mg IM?
- B. Obtain respirations and temperature.
- C. Dilute with 9 ml of NS.
- D. Draw the medications in separate syringes.
- E. Verify the route of administration.
Correct Answer: C
Rationale: Prochlorperazine (Compazine) is incompatible with other medications in the same syringe, so it must be drawn and administered separately from Stadol. Monitoring vital signs (e.g., blood pressure for orthostatic hypotension) is important but not the priority before administration. Dilution and route verification are unnecessary.
The nurse is caring for a homebound client with a urinary catheter. The client's husband states that he thinks the catheter is obstructed. Which of the following observations would confirm this suspicion?
- A. The nurse notes that the bladder is distended.
- B. The client complains of a constant urge to void.
- C. The nurse notes that the urine is concentrated.
- D. The client complains of a burning sensation.
Correct Answer: A
Rationale: bladder distention is one of the earliest signs of obstructed drainage tubing
The nurse is caring for a client with a history of eating disorders.
- A. Which client statement indicates a need for further teaching about anorexia nervosa?
- B. I need to gain weight slowly to stay healthy.'
- C. I can stop dieting once I reach my goal weight.'
- D. I should eat balanced meals regularly.'
- E. I need support to change my eating habits.'
Correct Answer: B
Rationale: Stating that dieting can stop at a goal weight suggests a misunderstanding, as anorexia requires ongoing nutritional and psychological management. Slow weight gain, balanced meals, and support are correct.