Nokea
The absence of which pulse may not be a significant finding when a patient is admitted to the hospital?
- A. Apical
- B. Radial
- C. Pedal
- D. Femoral
Correct Answer: C
Rationale: Pedal pulse absence is normal in 10-20% of people and less critical initially.
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Mr. Gary refused chemotherapy even if it will help his condition. The nurse respected his decision. This is an example of?
- A. Autonomy
- B. Beneficence
- C. Justice
- D. Fidelity
Correct Answer: A
Rationale: Respecting Mr. Gary's chemotherapy refusal is autonomy (A), per ethics honoring his choice. Beneficence (B) promotes good, justice (C) fairness, fidelity (D) promises not refusal-based. A aligns with self-rule, making it correct.
After a week, Mr. Gary's wife said 'If only I insisted an earlier check up, this wouldn't happen' This exemplifies what stage of grieving?
- A. Denial
- B. Anger
- C. Bargaining
- D. Depression
Correct Answer: C
Rationale: If only I insisted is bargaining (C), per Kubler-Ross seeking to undo loss via 'what ifs.' Denial (A) rejects, anger (B) rages, depression (D) despairs. Bargaining reflects guilt-driven deals, making it the correct stage.
When examining the client's abdomen, the nurse will most facilitate the examination by positioning the client in which of the following ways?
- A. supine with small pillows beneath knees and head
- B. semi-Fowler's position with knees extended
- C. sitting in the chair with legs elevated
- D. supine with arms extended and hands behind head
Correct Answer: A
Rationale: Supine with pillows under knees and head relaxes abdominal muscles, aiding examination, unlike semi-Fowler's, sitting, or arms-up positions. Nurses use this for effective assessment.
The nurse assesses a client at 40 weeks gestation and notes regular contractions and cervical dilatation of $6 \mathrm{~cm}$. Which actions by the nurse are important during this stage? Select all that apply.
- A. Administering the epidural injection
- B. Ensuring adequate hydration
- C. Encouraging the client to void
- D. Monitoring the condition of the fetus
Correct Answer: D
Rationale: At 40 weeks gestation with 6 cm cervical dilatation, the client is in active labor. Monitoring the fetus (D) is critical to assess for distress via heart rate patterns, a priority in labor management. Administering an epidural (A) requires an order and isn't universally needed. Ensuring hydration (B) supports labor but isn't the top action. Encouraging voiding (C) prevents bladder distension but is secondary. D is chosen. Rationale: Fetal monitoring detects hypoxia or distress, guiding interventions like position changes or delivery, per ACOG standards, outweighing comfort or supportive measures in immediacy during active labor.
You are caring for a client who has just returned from surgery and has received intravenous morphine minutes before leaving the recovery room. You need to assess the client's pain now and again at which of the following times?
- A. in 20 to 30 minutes
- B. in one hour
- C. in two hours
- D. in 3 to 4 hours
Correct Answer: A
Rationale: Post-morphine pain assessment at 20-30 minutes evaluates peak effect, critical post-surgery. Later checks miss this window. Nurses time this for efficacy.