Nokea
In obtaining an orthostatic vital sign measurement, what action should the nurse take first?
- A. Count the client's radial pulse
- B. Apply a blood pressure cuff
- C. Instruct the client to lie supine
- D. Assist the client to stand upright
Correct Answer: C
Rationale: The correct first action when obtaining an orthostatic vital sign measurement is to instruct the client to lie supine. This allows for establishing a baseline measurement of vital signs before any positional changes. Counting the client's radial pulse (Choice A) is a step that follows after the initial supine position to assess changes in pulse rate. Applying a blood pressure cuff (Choice B) and assisting the client to stand upright (Choice D) are actions that come later in the process after the baseline measurements are obtained in the supine position.
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A child with glomerulonephritis is admitted in the acute edematous phase. Based on this diagnosis, which nursing intervention should the PN plan to include in the child's plan of care?
- A. Recommend parents bring favorite snacks
- B. Encourage ambulation daily to the playroom
- C. Measure blood pressure every 4 to 6 hours
- D. Offer a selection of fresh fruit for each meal
Correct Answer: C
Rationale: The correct answer is to measure blood pressure every 4 to 6 hours. In glomerulonephritis, monitoring blood pressure is crucial as hypertension is a common complication. This helps in assessing the child's condition and response to treatment. Choice A, recommending parents bring favorite snacks, is not related to managing glomerulonephritis. Choice B, encouraging ambulation daily to the playroom, may not be appropriate during the acute edematous phase when the child may be experiencing fluid overload. Choice D, offering a selection of fresh fruit for each meal, is not directly relevant to managing the complications of glomerulonephritis.
The PN is caring for a laboring client whose last sterile vaginal examination revealed the cervix was 3 cm dilated, 50% effaced, and the presenting part was at 0 station. An hour later, the client tells the PN that she wants to go to the bathroom. Which action is most important for the PN to implement?
- A. Review the fetal heart rate and contraction pattern
- B. Check the perineum for an increase in bloody show
- C. Request a nurse to check the client's cervical dilation
- D. Palpate the client's bladder for distention
Correct Answer: C
Rationale: The sudden urge to use the bathroom may indicate that labor is progressing quickly. Checking the cervical dilation will help determine if the client is in the transition phase of labor and if it is appropriate to allow her to get up. Reviewing the fetal heart rate and contraction pattern (Choice A) is important but not the most immediate action in this scenario. Checking the perineum for an increase in bloody show (Choice B) is relevant but not as crucial as assessing cervical dilation. Palpating the client's bladder for distention (Choice D) is not the priority when the client wants to go to the bathroom during labor.
You are caring for a patient who just gave birth to a 6 lb. 13 oz. baby boy. The infant gave out a lusty cry, had a pink coloration all over his body, had flexed arms and legs, cried when stimulated, and had a pulse rate of 94. What Apgar score would you expect for this baby?
- A. 10
- B. 8
- C. 7
- D. 9
Correct Answer: D
Rationale: The Apgar score is a method used to quickly assess the health of newborns. In this scenario, the baby would receive 2 points for color, reflex irritability, and muscle tone, but only 1 point for a pulse rate of 94, resulting in an Apgar score of 9. An Apgar score of 9 indicates that the baby is in good health overall. Choice A (10) is incorrect because a pulse rate of 94 would only score 1 point. Choices B (8) and C (7) are incorrect as the given criteria would lead to a higher score, indicating the baby's good health.
Which condition is most commonly associated with a "bull's eye" rash?
- A. Lyme disease
- B. Rocky Mountain spotted fever
- C. Syphilis
- D. Toxoplasmosis
Correct Answer: A
Rationale: The correct answer is A: Lyme disease. The "bull's eye" rash, or erythema migrans, is a hallmark of early Lyme disease, caused by the bacterium Borrelia burgdorferi. Choice B, Rocky Mountain spotted fever, presents with a different type of rash. Choice C, Syphilis, typically presents with a painless ulcer and rash but not a "bull's eye" rash. Choice D, Toxoplasmosis, does not typically present with a "bull's eye" rash.
While caring for a client with a new tracheostomy, the nurse notices that the client is attempting to speak but is unable to. What should the nurse explain to the client regarding their inability to speak?
- A. Speaking is not possible because the tracheostomy tube blocks the vocal cords.
- B. The tracheostomy tube prevents air from reaching the vocal cords, making speech difficult.
- C. The client will regain the ability to speak once the tracheostomy tube is removed.
- D. The tracheostomy tube must be replaced with a speaking valve for the client to speak.
Correct Answer: B
Rationale: The correct answer is B. The tracheostomy tube bypasses the vocal cords, preventing air from reaching them, which is necessary for speech. This makes speaking difficult but not impossible. Removing the tracheostomy tube does not automatically restore the ability to speak (choice C). While a speaking valve can be added later to allow speech, initially, the tracheostomy tube itself hinders air from reaching the vocal cords, making speech difficult (choice D is incorrect). Choice A is incorrect as the tracheostomy tube does not block the vocal cords directly; instead, it prevents air from reaching them.