Nokea
All of the following are causes of vaginal bleeding in late pregnancy except:
- A. placenta previa.
- B. eclampsia.
- C. abruptio placentae.
- D. uterine rupture.
Correct Answer: B
Rationale: Eclampsia is a disorder of pregnancy characterized by hypertension, proteinuria, and edema. This condition can cause seizure and/or coma. Choices 1 and 3 are abnormal conditions that can cause bleeding, particularly in the third trimester. Choice 4 is a major obstetrical emergency that can cause bleeding internally and externally.
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A client is diagnosed with methicillin resistant staphylococcus aureus pneumonia (MRSA). What type of isolation is most appropriate for this client?
- A. Reverse
- B. Airborne
- C. Standard precautions
- D. Contact
Correct Answer: D
Rationale: Contact precautions or Body Substance Isolation (BSI) involves the use of barrier protection (e.g. gloves, mask, gown, or protective eyewear as appropriate) whenever direct contact with any body fluid is expected.
The nurse is caring for a client with a newly applied long leg cast. Which of these actions should the nurse take first to prevent complications from the cast?
- A. Check pedal pulses bilaterally
- B. Elevate the leg on pillows
- C. Apply ice to the cast
- D. Instruct the client to wiggle toes hourly
Correct Answer: A
Rationale: Checking pedal pulses bilaterally is the first action to ensure adequate circulation and detect potential complications like compartment syndrome early.
The nurse teaching a client about hepatitis and its transmission should explain that one type of hepatitis does not produce a carrier state after its acute phase. Which type is it?
- A. hepatitis A
- B. hepatitis B
- C. hepatitis C
- D. hepatitis D
Correct Answer: A
Rationale: Hepatitis A does not produce a carrier state. It is transmitted via contaminated water or food via the oral-fecal route and is not blood borne.
The nurse asks the NA to apply a mitten restraint for the client seated in the wheelchair next to the bed. Which observation by the nurse indicates that the NA needs further instructions on applying restraints?
- A. Restraint strap is tied to the bed frame next to the client.
- B. Restraint straps are secured using a half-bow slip knot.
- C. Two fingers can be inserted between the restraint and client's skin.
- D. Mesh portion of the mitten restraint is on the back of the hand.
Correct Answer: A
Rationale: Tying the restraint to the bed frame instead of the wheelchair frame risks injury if the wheelchair moves, indicating the NA needs further instruction.
The nurse suspects that a child may have ingested a caustic substance. Which comment by the child would be of greatest concern to the nurse?
- A. Ask the child if the mouth is burning or throat pain is present.'
- B. I feel sleepy and my stomach hurts.'
- C. My tongue feels funny and I’m thirsty.'
- D. Has the child had vomiting, diarrhea or stomach cramps?'
Correct Answer: A
Rationale: Local irritation of tissues indicates a corrosive poisoning. Burning in the mouth or throat pain suggests ingestion of a caustic substance, requiring immediate attention.