Nokea
A young woman who is at 32 weeks gestation reports to the physician's office for a routine prenatal visit. Which comment by the woman must be reported to the physician?
- A. I had to stop wearing my rings because my fingers are swollen.'
- B. I seem to be hotter than everyone else.'
- C. My feet tend to swell in the hot weather.'
- D. My breasts are so big and tender.'
Correct Answer: A
Rationale: Finger swelling severe enough to prevent wearing rings may indicate preeclampsia, requiring physician evaluation. Heat sensation, foot edema, and breast changes are normal in pregnancy.
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An adult client with a nasogastric tube has an order for acetaminophen (Tylenol) 650 mg PRN for a temperature greater than 101°F (38.3°C).
Which of the following measures should be included by the nurse when administering this medication?
- A. The tablets should be swallowed carefully with sips of water.
- B. The medication should be withheld until the nasogastric tube is removed.
- C. Placement of the nasogastric tube should be checked prior to giving the medication.
- D. Powdered medication should be used and mixed with water to form a solution.
Correct Answer: C
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) client is NPO, so nothing should be administered orally (2) medication should not be withheld (3) correct-liquid acetaminophen may be administered via the nasogastric tube after tube placement has been checked; tube placement should be checked before anything is instilled (4) Tylenol does not come powdered
A client with severe bilateral peripheral edema.
Which of the following is the BEST way for the nurse to determine the degree of edema in a limb, and the client's response to treatment?
- A. Measure both limbs with the tape measure and compare.
- B. Depress the skin and rank the degree of pitting.
- C. Describe the swelling in the affected area.
- D. Pinch the skin and note how quickly it returns to normal.
Correct Answer: B
Rationale: Strategy: Think about each answer choice. (1) is not the best way to evaluate for peripheral edema (2) correct-severity of edema is characterized by grading it 1+ (2-mm pitting) to 4+ (8-mm pitting) (3) not as objective (4) is used for evaluating hydration
The nurse is bathing a client who has contact isolation ordered. The nurse wears gloves. What else is needed?
- A. Face mask
- B. Sterile gloves
- C. Isolation cap
- D. Isolation gown
Correct Answer: D
Rationale: An isolation gown prevents contact transmission, required alongside gloves for bathing a client in contact isolation.
A child in Bryant's traction. The nurse notes that the foot of the uninjured leg feels warmer to touch than that of the broken leg during neurovascular assessment.
The nurse should
- A. record the observation.
- B. encourage the child to move the foot.
- C. cover the colder foot with a sock.
- D. notify the physician.
Correct Answer: D
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) ignores possibility that Ace bandage is too tight (2) does not relieve the circulation problem (3) does not relieve the circulation problem (4) correct-assessment indicates that Ace bandage is too tight and needs readjusting
A 9-year-old is admitted with suspected rheumatic fever. Which finding is suggestive of Syndeham's chorea?
- A. Irregular movements of the arms and legs and facial grimacing
- B. Painless swellings over the surface of the joints
- C. Faint areas of red demarcation over the back
- D. Swelling and inflammation of the joints
Correct Answer: A
Rationale: Syndeham's chorea is characterized by irregular, involuntary movements and facial grimacing, so A is correct. Answers B, C, and D describe other rheumatic fever symptoms but not chorea.