Nokea
A woman who is at 39 weeks gestation enters the hospital in early labor. Several hours later, she says, 'What's happening? I suddenly feel as though I have to have a bowel movement.' The woman starts bearing down as if to push out stool. What is the best initial action for the licensed practical nurse at this time?
- A. Encourage her to push
- B. Ask her to pant
- C. Immediately call the charge nurse
- D. Ask her when she last had a bowel movement
Correct Answer: B
Rationale: The urge to have a bowel movement and bearing down indicate advanced labor or delivery. Panting prevents pushing, allowing time to assess and prepare for delivery.
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The nurse is caring for a client who has been started on sulfamethoxazole/trimethoprim for a urinary tract infection. It is most important for the nurse to follow up on which client statement?
- A. I go to the bathroom a lot more than usual
- B. It burns when I pee.
- C. My urine is cloudy
- D. There is a red rash on my abdomen.
Correct Answer: D
Rationale: A rash may indicate an allergic reaction, requiring urgent follow-up. Frequent urination , burning , and cloudy urine are UTI symptoms.
The nurse is preparing a client with a deep vein thrombosis (DVT) for a Venous Doppler evaluation. Which of the following would be necessary for preparing the client for this test?
- A. Client should be NPO after midnight
- B. Client should receive a sedative medication prior to the test
- C. Discontinue anti-coagulant therapy prior to the test
- D. No special preparation is necessary
Correct Answer: D
Rationale: This is a non-invasive procedure and does not require preparation other than client education.
A nurse is caring for a client with blindness due to diabetic retinopathy. Which interventions should the nurse implement for this client? Select all that apply.
- A. Ask a family member about the client's preferences for room arrangement
- B. Offer the client an elbow to hold, and walk a half-step ahead for guidance
- C. Say 'goodbye' when leaving the room to help orient the client
- D. Speak slowly and slightly louder so the client can understand
- E. Use a clock-face pattern to explain food arrangement on the client's meal tray
Correct Answer: B,C,E
Rationale: Guiding with an elbow , saying goodbye , and clock-face food arrangement promote safety and orientation. Family input is secondary, and louder/slower speech is unnecessary unless hearing-impaired.
An adult is admitted with a pneumothorax following an accident. Immediately after insertion of a chest tube, the client says to the nurse, 'Why do I have a tube in my chest and that thing hanging on the side of the bed? I don't like it.' What should the nurse include when replying to the client?
- A. Tell the client that the chest tube helps the client take bigger breaths
- B. Focus on the client's feelings
- C. Explain that the chest tube will remove air and/or fluid from the pleural cavity and allow the lung to reexpand
- D. Tell the client that the nurse will contact the physician to have it removed
Correct Answer: C
Rationale: The chest tube drains air/fluid from the pleural space, allowing lung re-expansion in pneumothorax, providing an accurate, educational response to the client's question.
The nurse is observing a nursing assistant providing care. Which action indicates that the nursing assistant understands universal precautions?
- A. The nursing assistant washes hands first thing in the morning before giving care to any client and again after all morning care is completed.
- B. The nursing assistant wears gloves during all client contact.
- C. The nursing assistant wears a gown when changing linen soiled with urine and feces.
- D. The nursing assistant changes gloves between clients but does not wash hands if gloves have been worn.
Correct Answer: C
Rationale: Wearing a gown for soiled linen contact adheres to universal precautions, preventing contamination. Limited hand washing, excessive gloves, or no hand washing post-gloves are incorrect.