Nokea
At 26 weeks gestation, a client is admitted to the ER stating that she has been having a painless bloody vaginal discharge since last evening. The nurse should give priority to:
- A. Reporting the findings to the physician
- B. Evaluating the color of the discharge
- C. Evaluating the client's vital signs
- D. Applying an external fetal monitor
Correct Answer: A
Rationale: Painless bleeding at 26 weeks suggests placenta previa or abruption, requiring immediate physician notification . Assessing discharge , vitals , or fetal monitoring follows reporting.
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The nurse has reinforced teaching about formula preparation with the parent of a newborn. Which of the following statements by the parent would indicate a correct understanding of the teaching? Select all that apply.
- A. I should avoid using the microwave to heat my baby's formula.
- B. I must wash the top of the concentrated formula can before opening it.
- C. If my baby is feeding poorly, I should use less water to dilute the formula.
- D. Prepared formula should be kept in the refrigerator and discarded after 24 hours.
- E. Bottled water does not need to be boiled when used to reconstitute powdered formula.
Correct Answer: A,B,D
Rationale: Microwaving (A) can cause uneven heating, risking burns, so it’s avoided. Washing the can top (B) prevents contamination. Refrigerated formula must be discarded after 24 hours (D) to prevent bacterial growth. Diluting less (C) alters nutrition, and bottled water (E) may need boiling depending on safety, indicating incorrect understanding.
The nurse is caring for assigned clients. The nurse should first check the
- A. 3-year-old client who has fever and right hip pain and is refusing to move the right leg
- B. 7-year-old client who has sinus congestion and a productive cough
- C. 10-year-old client who has an active nosebleed and is applying pressure to the nose
- D. 12-year-old client who has fever, urinary frequency, and dysuria
Correct Answer: A
Rationale: A 3-year-old with fever, hip pain, and refusal to move the leg (A) may indicate a serious condition like septic arthritis or osteomyelitis, requiring immediate assessment to prevent joint damage or systemic infection. Sinus congestion (B) and urinary symptoms (D) are less urgent, and the nosebleed (C) is being managed with pressure, making them lower priorities.
A nurse prepared the 9:00 A.M. medications for his clients and then was called off the unit briefly before he was able to administer them. Who may administer the medications to the clients now?
- A. Any licensed nurse assigned to the unit and familiar with the clients
- B. A pharmacy technician certified to administer medications
- C. The nurse who prepared them
- D. The nurse manager of the unit
Correct Answer: C
Rationale: The nurse who prepared the medications must administer them to ensure accountability and familiarity with the preparation.
The nurse is caring for a client with schizophrenia who is experiencing visual hallucinations. The client states, 'There is a bad person standing in my room.' Which of the following responses would be most appropriate for the nurse to make?
- A. Your illness is making you experience visual hallucinations.'
- B. I know you are frightened, but I do not see anyone in your room.'
- C. Do not worry. I will give you medication that will make the bad person go away.'
- D. We will go into the dayroom and play a game. I know you like to play board games.'
Correct Answer: B
Rationale: When addressing hallucinations, the nurse should acknowledge the client’s fear while gently reinforcing reality. Response B validates the client’s emotions and clarifies that the nurse does not see the hallucination, maintaining trust without reinforcing the delusion. Labeling the hallucination as part of the illness (A) may confuse or alienate the client. Promising medication will resolve it (C) oversimplifies treatment, and distracting with games (D) dismisses the client’s distress.
Which of these clients would be appropriate to assign to a practical nurse (PN)?
- A. A trauma victim with multiple lacerations and requires complex dressings
- B. An elderly client with cystitis and an indwelling urethral catheter
- C. A confused client whose family complains about the nursing care 2 days after surgery
- D. A client admitted for possible transient ischemic attack with unstable neurological signs
Correct Answer: B
Rationale: This is a stable client, with predictable outcome and care and minimal risk for complications.