Nokea
A woman at 38-weeks gestation comes to the emergency room with complaints of vaginal bleeding.
- A. Which statement by a woman at 38-weeks gestation with vaginal bleeding suggests placenta previa?
- B. I feel fine, but the bleeding scares me.'
- C. I’ve been more nauseated during the past few weeks.'
- D. The bleeding started after I carried four bags of groceries.'
- E. I’ve been having severe abdominal cramps.'
Correct Answer: A
Rationale: Placenta previa is characterized by painless vaginal bleeding, as the placenta covers the cervical os. The statement ‘I feel fine, but the bleeding scares me’ indicates bleeding without pain, consistent with placenta previa. Nausea, activity-related bleeding, or cramps suggest other causes like abruptio placentae.
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The nurse is caring for a client who is receiving a blood transfusion. Which of the following findings would be of GREATest concern to the nurse?
- A. Temperature of 100.4°F (38°C).
- B. Heart rate of 90 bpm.
- C. Respiratory rate of 18 breaths/min.
- D. Blood pressure of 120/80 mmHg.
Correct Answer: A
Rationale: A temperature of 100.4°F during a blood transfusion suggests a transfusion reaction, such as febrile non-hemolytic reaction, requiring immediate cessation of the transfusion. Options B, C, and D are normal: heart rate 90 bpm, respiratory rate 18 breaths/min, and blood pressure 120/80 mmHg do not indicate complications.
An adult client who had major abdominal surgery is returned to her room on the surgical nursing unit. The postanesthesia nurse reports that the client is awake and has stable vital signs. She has a nasogastric tube in place that is attached to intermittent suction. How should the nurse position the client?
- A. Supine
- B. Semi-sitting
- C. Dorsal recumbent
- D. Prone
Correct Answer: B
Rationale: Semi-sitting facilitates breathing, reduces aspiration risk with a nasogastric tube, and promotes comfort post-abdominal surgery. Supine or dorsal recumbent increases aspiration risk, and prone is contraindicated.
When the nurse walks into a client's room, the client states, 'I just love hot-blooded redheads.' The client pats his bed and says, 'Why don't you sit down here and get off your feet for a while.'
Which of the following responses by the nurse is BEST?
- A. I feel very uncomfortable when you make those suggestive remarks. It makes it difficult for me to do my job.'
- B. I don't think my husband or your wife would like me doing that.'
- C. You must be very lonesome. I'll come back later and spend some time with you.'
- D. I bet you flirt with all the nurses like that.'
Correct Answer: A
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-nurse should confront client about inappropriate sexual behavior (2) should confront the client (3) reinforces inappropriate behavior (4) confront the client about inappropriate and unwanted behavior
The nurse is caring for a client with a history of heart failure who is receiving carvedilol (Coreg) 6.25 mg PO bid. Which of the following findings should the nurse report immediately?
- A. Blood pressure of 90/60 mmHg.
- B. Heart rate of 70 bpm.
- C. Respiratory rate of 18 breaths/min.
- D. Oxygen saturation of 95%.
Correct Answer: A
Rationale: Hypotension (90/60 mmHg) is a serious carvedilol side effect, risking perfusion in heart failure. Options B, C, and D are normal.
A client taking isoniazid (INH) for tuberculosis asks the nurse about side effects of the medication. The client should be instructed to immediately report which of these?
- A. Double vision and visual halos
- B. Extremity tingling and numbness
- C. Confusion and lightheadedness
- D. Sensitivity of sunlight
Correct Answer: B
Rationale: Extremity tingling and numbness. Peripheral neuropathy is the most common side effect of INH and should be reported to the provider. It can be reversed.