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At 42-weeks gestation, a client refuses induction and desires a natural delivery. What is the most important action for the nurse to take?
- A. Discuss alternative ways to support her birth plan.
- B. Explain the indications for induction in post-term pregnancy.
- C. Discuss the differences between labor with oxytocin and natural labor.
- D. Ask the healthcare provider to discuss the issue with the client.
Correct Answer: A
Rationale: The correct answer is to discuss alternative ways to support her birth plan. It is crucial to respect the client's autonomy and desires while ensuring their safety and well-being. Choice B is incorrect because while educating the client about the indications for induction is important, it is not the most immediate action to take in this scenario. Choice C is incorrect as it focuses on comparing labor types rather than supporting the client's birth plan. Choice D is incorrect as the nurse should first engage with the client directly before involving the healthcare provider.
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A client presents with severe dehydration due to prolonged vomiting. What is the nurse's priority intervention?
- A. Encourage the client to drink clear fluids.
- B. Assess the client's skin turgor and mucous membranes.
- C. Monitor the client's vital signs frequently.
- D. Administer an antiemetic as prescribed.
Correct Answer: B
Rationale: The correct answer is to assess the client's skin turgor and mucous membranes. When a client presents with severe dehydration, assessing skin turgor (elasticity of the skin) and mucous membranes (such as checking for dryness in the mouth) is crucial in determining the extent of dehydration. Encouraging the client to drink clear fluids (Choice A) may be important but assessing dehydration severity takes precedence. Monitoring vital signs (Choice C) is essential but assessing dehydration status comes first. Administering an antiemetic (Choice D) addresses vomiting but does not directly assess dehydration.
A client presents with three positive responses to the CAGE questionnaire. What interpretation should the nurse provide?
- A. CAGE is a tool for general substance abuse screening.
- B. Two positive responses suggest alcohol dependence.
- C. One positive response does not indicate alcohol addiction.
- D. All four responses must be positive to suggest alcohol dependence.
Correct Answer: B
Rationale: Two positive responses on the CAGE questionnaire strongly suggest alcohol dependence. Choice A is incorrect as the CAGE questionnaire specifically targets alcohol abuse. Choice C is incorrect because one positive response is not enough to indicate alcohol addiction. Choice D is incorrect because alcohol dependence can be suggested with two positive responses, not all four.
The healthcare provider is performing a physical assessment on a client who just had an endotracheal tube inserted. Which finding would call for immediate action by the healthcare provider?
- A. Breath sounds are audible bilaterally
- B. Mist is visible in the T-piece
- C. Pulse oximetry of 88
- D. Client is unable to verbalize
Correct Answer: C
Rationale: A pulse oximetry reading of 88 indicates hypoxia, which is a serious condition requiring immediate intervention. Adequate oxygenation is crucial for the client's well-being. Choices A and B are normal findings after endotracheal intubation. Hearing bilateral breath sounds and seeing mist in the T-piece indicate proper functioning of the endotracheal tube. While choice D may indicate an issue with speaking due to the endotracheal tube, it is not as critical as the hypoxia indicated by the low pulse oximetry reading.
A client is receiving treatment for glaucoma. Which class of medications is commonly used to decrease intraocular pressure?
- A. Anticholinergics
- B. Beta blockers
- C. Alpha blockers
- D. Diuretics
Correct Answer: D
Rationale: Diuretics are commonly used to decrease intraocular pressure in clients with glaucoma. They work by reducing the production of aqueous humor in the eye or by increasing its outflow. Anticholinergics (Choice A) are not typically used in the treatment of glaucoma and can even increase intraocular pressure. Beta blockers (Choice B) are also commonly used in glaucoma treatment as they reduce aqueous humor production. Alpha blockers (Choice C) are not the first-line treatment for glaucoma and are not as commonly used as diuretics or beta blockers.
Which of these clients, all in the terminal stage of cancer, is least appropriate to suggest the use of patient-controlled analgesia (PCA) with a pump?
- A. A young adult with a history of Down syndrome
- B. A teenager who reads at a 4th-grade level
- C. An elderly client with numerous arthritic nodules on the hands
- D. A preschooler with intermittent alertness episodes
Correct Answer: D
Rationale: The correct answer is D. A preschooler with intermittent alertness episodes is not a suitable candidate for patient-controlled analgesia (PCA) due to their inability to effectively manage the system. In the context of terminal cancer, it is crucial for the patient to be able to utilize the PCA system appropriately to manage pain effectively. Preschoolers may not have the cognitive ability or understanding to operate a PCA pump compared to the other clients. Choices A, B, and C present clients with conditions that do not inherently impede their ability to use a PCA pump effectively.