Nokea
A primigravida arrives at the labor unit stating that she is having contractions. Which statement describes the presence of true contractions?
- A. True contractions begin in the lower abdomen.
- B. True contractions have a consistent frequency.
- C. True contractions lessen with physical activity.
- D. True contractions are inconsistent in frequency.
Correct Answer: B
Rationale: True contractions have a consistent frequency , becoming regular and stronger. They start in the back or upper abdomen (A is incorrect), intensify with activity (C is incorrect), and are regular (D is incorrect).
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An 80-year-old woman has been hospitalized for three days with pneumonia. She is now able to sit in a chair for the first time. How should the nurse plan care for today?
- A. Give her a bed bath and make her bed. Get her up in the chair later.
- B. Get her up in the chair and have her give herself a bath while the nurse makes the bed.
- C. Give her a bed bath and come back later to get her up in the chair. Make the bed while she is up in the chair.
- D. Give her a bed bath and immediately get her up in the chair so the bed can be made.
Correct Answer: C
Rationale: A bed bath conserves energy, and later chair transfer allows bed-making, optimizing rest and mobility for a recovering pneumonia patient.
A culture is taken of a lesion suspected of being herpes. The nurse knows that the specimen:
- A. Should be packed on ice
- B. Should be kept warm
- C. Should be double bagged
- D. Requires no special handling
Correct Answer: A
Rationale: Herpes culture specimens should be packed on ice to preserve the virus for accurate laboratory testing.
The nurse is suctioning an adult's tracheostomy tube. What action is essential before starting to suction the client?
- A. Have the client drink a glass of water to liquefy secretions
- B. Administer high levels of oxygen to the client
- C. Have the client sign a permit for suctioning
- D. Give the client a pad of paper and a pencil so he can communicate while the nurse suctions
Correct Answer: B
Rationale: Pre-oxygenation with high oxygen levels prevents hypoxia during tracheostomy suctioning, critical for patient safety, unlike water, consents, or communication aids.
When the nurse is caring for a client receiving a neuroleptic medication exhibiting torticollis and involuntary muscle movement, what is the priority nursing action?
- A. Have respiratory support equipment available
- B. Administer an antiemetic medication
- C. Monitor the client’s temperature closely
- D. Administer an antihistamine
Correct Answer: A
Rationale: Have respiratory support equipment available. These side effects could lead to respiratory failure, necessitating immediate respiratory support.
A patient has been ordered to get Tegretol for the first time. Which of the following side effects is not associated with Tegretol?
- A. Sore throat
- B. Vertigo
- C. Fever
- D. Shortness of breath
Correct Answer: D
Rationale: A-C are associated side effects of Tegretol.