Nokea
After the shift report in a labor and delivery unit which of these clients would the nurse check first?
- A. A middle aged woman with asthma and Type 1 diabetes mellitus has a BP of 150/94
- B. A middle aged woman with a history of two prior vaginal term births is 2 cm dilated
- C. A young woman who is a grand multipara has cervical dilation of 4 cm and is 50% effaced
- D. An adolescent who is 18 weeks pregnant has a report of no fetal heart tones and coughing up frothy sputum
Correct Answer: D
Rationale: This client has an actual complication. The others present with findings of potential complications. The adolescent’s symptoms suggest a serious condition, possibly pulmonary edema or fetal demise, requiring immediate assessment.
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A client diagnosed with metastatic cancer of the bone is exhibiting mental confusion and a BP of 160/100. Which laboratory value would correlate with the client's symptoms reflecting a common complication with this diagnosis?
- A. Potassium 5.2 mEq/l
- B. Calcium 13 mg/dl
- C. Inorganic phosphorus 1.7 mEq/l
- D. Sodium 138 mEq/l
Correct Answer: B
Rationale: Hypercalcemia is a common occurrence with cancer of the bone. The potassium level is elevated but does not relate to the diagnosis, so answer A is incorrect. Answers C and D are both normal levels, so they are incorrect.
An 18-month-old child has been placed in Bryant's traction. The nurse knows that the traction is properly applied when:
- A. the affected leg is extended and attached to traction at the foot of the bed.
- B. the legs are at right angles to the child's body and the buttocks are two inches off the bed.
- C. the legs are at right angles to the child's body and the nurse can just put his/her fingers underneath the child's buttocks.
- D. the affected leg is extended and attached to traction at the foot of the bed and there is a vertical pull at the popliteal area.
Correct Answer: C
Rationale: Bryant's traction for infants involves both legs at 90 degrees to the body, with buttocks slightly off the bed (fingers can fit underneath), ensuring proper alignment and traction force.
The nurse is caring for a 5-year-old client who is dehydrated and malnourished, and suspects that the client may be neglected. Which information most strongly supports the nurse's suspicion of child neglect?
- A. The parent cannot stay at the hospital due to potential job loss from absence
- B. The parent is in the process of a divorce and will soon be a single parent
- C. The parent is witnessed stealing food and drinks from the cafeteria
- D. The parent leaves the client's younger sibling to care for the client's newborn sibling
Correct Answer: D
Rationale: Leaving a young child to care for a newborn indicates inadequate supervision, supporting neglect. Job constraints , divorce , and stealing food suggest stress but not direct neglect.
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.
Which of the following nursing assessment findings require immediate discontinuance of an antipsychotic medication?
- A. Involuntary rhythmic stereotypic movements and tongue protrusion
- B. Cheek puffing, involuntary movements of extremities and trunk
- C. Agitation, constant state of motion
- D. Hyperpyrexia, severe muscle rigidity, malignant hypertension
Correct Answer: D
Rationale: Hyperpyrexia, severe muscle rigidity, and malignant hypertension are signs of neuroleptic malignant syndrome (NMS), requiring immediate discontinuation of the antipsychotic.