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At 32 weeks' gestation, a client is scheduled for a fetal activity test (nonstress test). She calls the clinic and asks the RN, 'How do I prepare for the test I am scheduled for?' The RN will most likely inform her of the following instructions to help prepare her for the test:
- A. You need to know that an IV is always started before the test.
- B. You will need to drink 6 to 8 glasses of water to fill your bladder.
- C. Do not eat any food or drink any liquids before the test is started.
- D. You will have to remain as still as you possibly can.
Correct Answer: D
Rationale: Any maternal activity can interfere with the results of the nonstress test, as movement may affect fetal heart rate tracings.
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The nurse observes a client crying quietly. She has just experienced a spontaneous abortion at nine weeks' gestation. An appropriate response by the nurse would be:
- A. It must be God's will and probably is for the best.'
- B. This must be a difficult time for you. Would you like to talk about it?'
- C. I'm sure your other children will be a comfort for you.'
- D. Don't worry, you're still young. If I were you I'd just try again.'
Correct Answer: B
Rationale: This response is nontherapeutic because it belittles the client's response and gives a meaningless rationalization. This response acknowledges the client's feelings and demonstrates the therapeutic offering of self by the nurse. This response is nontherapeutic because it does not focus on the client's feelings and offers false reassurance. This response is nontherapeutic because it belittles the client's feelings and offers her advice.
A cardinal symptom of the schizophrenic client is hallucinations. A nurse identifies this as a problem in the category of:
- A. Impaired communication
- B. Sensory-perceptual alterations
- C. Altered thought processes
- D. Impaired social interaction
Correct Answer: B
Rationale: Impaired communication refers to decreased ability or inability to use or understand language in an interaction. In sensory-perceptual alterations an individual has distorted, impaired, or exaggerated responses to incoming stimuli (i.e., a hallucination, which is a false sensory perception that is not associated with real external stimuli). An altered thought processes problem statement is used when an individual experiences a disruption in cognitive operations and activities (i.e., delusions, loose associations, ideas of reference). In impaired social interaction, the individual participates too little or too much in social interactions.
The nurse is assessing an adult female client for hypovolemia.
- A. Hematocrit 55%
- B. Potassium 5.0 mEq/L
- C. Urine specific gravity 1.016
- D. BUN 18 mg/dL
Correct Answer: A
Rationale: Elevated hematocrit (55%) indicates hemoconcentration due to fluid loss in hypovolemia. Potassium (B) and BUN (D) are within normal ranges, and urine specific gravity (C) is normal, not elevated as expected in hypovolemia.
The nurse is preparing to administer a feeding via a nasogastric tube. The nurse would perform which of the following before initiating the feeding?
- A. Assess for tube placement by aspirating stomach content.
- B. Place the patient in a left-lying position.
- C. Administer feeding with 50% Dextrose.
- D. Ensure that the feeding solution has been warmed in a microwave for two minutes.
Correct Answer: A
Rationale: Verifying nasogastric tube placement by aspirating stomach contents (and checking pH) is critical to prevent aspiration. Left-lying position is incorrect, 50% dextrose is inappropriate, and microwaving can cause burns or nutrient degradation.
The nurse is preparing to administer digoxin (Lanoxin) to a client with heart failure. The client’s heart rate is 58 beats per minute. What is the nurse’s best action?
- A. Administer the digoxin as ordered.
- B. Hold the digoxin and notify the physician.
- C. Reduce the dose by half and administer.
- D. Monitor the client for 30 minutes, then administer.
Correct Answer: B
Rationale: A heart rate of 58 bpm is below the threshold (60 bpm) for digoxin administration, as it may worsen bradycardia. Holding the dose and notifying the physician (B) is safest. Administering (A), reducing (C), or delaying (D) is inappropriate.