Nokea
A primigravid client at 38 weeks' gestation reports decreased fetal movement. What is the nurse's first action?
- A. Perform a nonstress test.
- B. Notify the physician.
- C. Encourage the client to drink water.
- D. Auscultate fetal heart tones.
Correct Answer: D
Rationale: Auscultating fetal heart tones is the first step to assess fetal well-being in response to decreased movement, providing immediate data.
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The nurse is caring for a client with a history of cirrhosis. Which of the following laboratory findings indicates a worsening condition?
- A. Elevated ammonia levels.
- B. Decreased bilirubin levels.
- C. Increased albumin levels.
- D. Decreased prothrombin time.
Correct Answer: A
Rationale: Elevated ammonia levels indicate worsening liver function and potential hepatic encephalopathy in cirrhosis.
Which of the following is an adverse effect to therapeutic radiation therapy?
- A. Fibrosis
- B. Alopecia
- C. Oral dryness
- D. Xerostomia
Correct Answer: D
Rationale: Xerostomia (dry mouth) is a common adverse effect of radiation therapy, particularly when the head or neck is irradiated, due to damage to salivary glands.
A new breast-feeding mother experiencing breast engorgement is provided with instructions regarding care for the condition. Which statement by the mother indicates to the nurse that she possesses an understanding of the measures that will provide comfort for the engorgement?
- A. I will breast-feed using only one breast.
- B. I will apply cold compresses to my breasts.
- C. I will avoid the use of a bra while my breasts are engorged.
- D. I will massage my breasts before feeding to stimulate letdown.
Correct Answer: D
Rationale: Comfort measures for breast engorgement include massaging the breasts before feeding to stimulate letdown, alternating the breasts during feeding, taking a warm shower or applying warm compresses just before feeding, and wearing a supportive well-fitting bra at all times. None of the other options suggest correct measures.
A client is at risk for development of metabolic alkalosis because of persistent vomiting. The nurse should assess the client specifically for:
- A. Irritability.
- B. Hyperventilation.
- C. Diarrhea.
- D. Edema.
Correct Answer: B
Rationale: Persistent vomiting causes loss of hydrochloric acid, leading to metabolic alkalosis, which can manifest as hyperventilation as the body compensates for elevated pH.
The nurse is assessing a client with a history of heart failure who is receiving a 500-mL I.V. bolus of 0.9% normal saline. To evaluate the client's response to the treatment, the nurse should especially monitor the client for which of the following?
- A. Hypotension.
- B. Increased urine output.
- C. Crackles in the lungs.
- D. Dry mucous membranes.
Correct Answer: C
Rationale: In heart failure, fluid boluses can lead to pulmonary edema, so monitoring for lung crackles is critical to detect fluid overload.