Nokea
During the assessment of a laboring client, the nurse notes that the FHT are loudest in the upper-left quadrant. The infant is most likely in which position?
- A. Left mentum anterior
- B. Left occipital anterior
- C. Left sacral anterior
- D. Left occipital transverse
Correct Answer: B
Rationale: Fetal heart tones loudest in the upper-left quadrant suggest a left occipital anterior position, where the fetus's back is aligned with the mother's left side. Other positions` positions are less likely.
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Following Nitroglycerin patch application
An expected outcome experienced by the client would be one of the following:
- A. Elevated blood pressure
- B. Tachycardia
- C. Tingling sensation
- D. Increased urine output
Correct Answer: B
Rationale: Nitroglycerin may cause reflex tachycardia as a compensatory response to vasodilation.
A young female patient comes to the physician because she has been experiencing fatigue and double vision. The physician suspects myasthenia gravis.
When obtaining information from the patient, the nurse would expect her to report that:
- A. Her level of fatigue has been constant.
- B. The longer she rests the weaker she feels.
- C. Her strength increases with progressive activity.
- D. The symptoms seem more severe in the evening.
Correct Answer: D
Rationale: Myasthenia gravis symptoms worsen with activity and are more severe in the evening due to muscle fatigue.
The nurse observes a LPN/LVN perform a wet-to-dry dressing change on a 2-inch abdominal incision. Which of the following behaviors, if performed by the LPN/LVN, would indicate an understanding of proper technique?
- A. A clean cotton ball is used to cleanse from the top of the incision to the bottom of the incision using long strokes.
- B. The incision is packed with sterile gauze, and then sterile saline is poured over the dressing.
- C. The nurse packs wet gauze into the incision without overlapping it onto the skin.
- D. The old dressing is saturated with sterile saline before it is removed.
Correct Answer: C
Rationale: Wet-to-dry dressings should have wet gauze packed into the incision without overlapping onto the skin to prevent skin breakdown. Cleansing (A) should be from the center outward, dressings (B) are soaked before packing, and old dressings (D) are removed dry to debride the wound.
The nurse is caring for a client with tuberculosis. Which precautions should the nurse take when providing care for this client? Select all that apply:
- A. Wear gloves when handling tissues containing sputum
- B. Wear a face mask at all times
- C. Keep the client in strict isolation
- D. When the client leaves the room for tests, have all people in contact with him wear a mask
- E. Keep the client's door open to allow fresh air into room and prevent social isolation
- F. Wash hands after direct contact with the client or contaminated articles
Correct Answer: A,B,F
Rationale: The nurse should always wear gloves when handling items contaminated with sputum or body secretions. All staff and visitors must wear face masks when coming in contact with the client in his room; masks must be discarded before leaving the client's room. Hand washing is required after direct contact with the client or contaminated articles. Strict isolation isn't required if the client adheres to special respiratory precautions. The client, not the people in contact with him, must wear a mask when leaving the room for tests. The client should be in a negative-pressure, private room, and the door should remain closed at all times to prevent the spread of infection.
A 35-year-old male has been an insulin-dependent diabetic for five years and now is unable to urinate.
Which of the following would you most likely suspect?
- A. Atherosclerosis
- B. Diabetic neuropathy
- C. Autonomic neuropathy
- D. Somatic neuropathy
Correct Answer: C
Rationale: Autonomic neuropathy can impair bladder function, causing urinary retention in long-term diabetes.