Nokea
A spinal change occurring with pregnancy that alters mobility is:
- A. scoliosis.
- B. kyphosis.
- C. lordosis.
- D. ankylosing spondylitis.
Correct Answer: C
Rationale: The spinal change occurring with pregnancy is lordosis. This occurs due to the weight of the enlarging uterus and the affect of gravity.
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The intent of the Patient Self Determination Act (PSDA) of 1990 is to:
- A. enhance personal control over legal care decisions
- B. encourage medical treatment decision making prior to need
- C. give one federal standard for living wills and durable powers of attorney
- D. emphasize client education
Correct Answer: B
Rationale: The PSDA encourages advance directives to promote proactive medical decision-making, ensuring clients' wishes are honored before a crisis.
The nurse needs nasotracheal suctioning. The nurse explains the procedure to the client and performs hand hygiene. Prioritize the nurse's remaining actions to perform the nasotracheal suctioning by placing each step in the correct order.
- A. Prepare suction supplies and equipment and pour sterile saline into a sterile container.
- B. Place finger over suction control port of catheter and suction intermittently while withdrawing the catheter.
- C. Put on sterile gloves.
- D. Lubricate the catheter with sterile saline, insert into naris, and advance into pharynx.
- E. When the client inhales, advance the catheter into the trachea.
- F. Pick up suction catheter with the dominant hand and attach it to connection tubing; avoid contamination of the glove on the dominant hand.
- G. Place tip into sterile saline container while applying suction to clear secretions from the tubing
Correct Answer: A,C,F,D,E,B,G
Rationale: A: Preparing supplies comes first. C: Sterile gloves maintain asepsis. F: Handling catheter keeps dominant hand sterile. D: Lubrication aids insertion. E: Advancing during inhalation ensures tracheal placement. B: Intermittent suction prevents trauma. G: Clearing tubing prevents reinsertion of secretions.
When making an occupied bed, it is important for the nurse to:
- A. keep the bed in the low position.
- B. use a bath blanket or top sheet for warmth and privacy.
- C. constantly keep side rails raised on both sides.
- D. move back and forth from one side to the other when adjusting the linens.
Correct Answer: B
Rationale: Using a bath blanket or top sheet keeps the client warm and provides privacy. Keeping the bed in the low position and working above raised side rails might strain the nurse's back. Continually moving back and forth to tuck and arrange linen is time-consuming and disorganized.
The client with intermittent abdominal pain recently had a barium enema. The client calls the nurse to report passage of a soft-formed, pale-colored stool. What is the nurse's best response?
- A. This is an expected finding after administration of barium.
- B. Describe any abdominal pain you had when passing the stool.
- C. What foods or fluids did you eat after you completed the test?
- D. You need to increase the amount of water you are drinking.
Correct Answer: A
Rationale: A: Pale stools are expected due to residual barium. B: Pain doesn't cause pale stools. C: Diet doesn't affect barium-related stool color. D: Water aids barium passage but isn't indicated for soft stools.
A hospitalized adult client who routinely works from midnight until 8 a.m. has a temperature of 99.1°F at 4 a.m. The nurse determines that this is most likely due to:
- A. delta sleep
- B. slow brain waves
- C. pneumonia
- D. circadian rhythm
Correct Answer: D
Rationale: Biological rhythms that follow a cycle lasting about 24 hours are termed circadian rhythm. The sleep-wake cycle is closely linked with cardiac rhythms, such as body temperature. While a person sleeps, core body temperature drops, often reaching the 24-hour low at 4 a.m. When the sleep period shifts, temperature fluctuations also shift to match the new sleep patterns.