Nokea
The APGAR is performed at what minutes?
- A. 1 and 5
- B. 2 and 4
- C. 5 and 10
- D. At birth and 5 minutes
Correct Answer: A
Rationale: The APGAR score is a quick assessment tool used to evaluate a newborn's health and overall condition immediately after birth and again at 5 minutes after birth. The five categories evaluated in the APGAR score are Appearance, Pulse, Grimace, Activity, and Respiration. The assessment is typically done at 1 minute and 5 minutes after birth to quickly determine if the baby needs any immediate medical attention or interventions. The scores at both time points provide valuable information about the baby's well-being and can guide healthcare providers in deciding on appropriate next steps for care.
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A patient calls and says she used her diaphragm on Saturday night at 8:00 p.m., again on Sunday morning at 2:00 a.m., and again at 8:00 a.m. She is wondering when she can safely remove it while still having effective contraception. What is the nurse’s best response?
- A. 10:00 a.m. Sunday
- B. 2:00 p.m. Sunday
- C. 10:00 p.m. Sunday
- D. 8:00 a.m. Monday
Correct Answer: D
Rationale: In general, a diaphragm should be left in place for at least 6 hours after intercourse but no more than 24 hours. Based on the patient's usage times on Saturday night at 8:00 p.m., Sunday morning at 2:00 a.m., and Sunday morning at 8:00 a.m., she can safely remove the diaphragm on Monday morning at 8:00 a.m. This ensures she has used it for the necessary timeframe for effective contraception.
A client with acute respiratory failure (ARF) may present with which of the following manifestations? (Select one that doesn't apply.)
- A. Severe dyspnea
- B. Decreased level of consciousness
- C. Headache
- D. Nausea
Correct Answer: D
Rationale: In acute respiratory failure (ARF), the body is not getting enough oxygen, leading to respiratory distress. Symptoms of ARF typically include severe dyspnea (difficulty breathing), decreased level of consciousness due to hypoxia, and headache from inadequate oxygenation to the brain. Nausea is not a typical manifestation of ARF and would not be expected in this condition.
The nurse is monitoring a client with premature rupture of membranes at 37 weeks. Which prescription should the nurse question?
- A. Monitor fetal heart rate continuously.
- B. Monitor maternal vital signs frequently.
- C. Perform a vaginal examination every shift.
- D. Administer an antibiotic as prescribed.
Correct Answer: C
Rationale: Vaginal exams are minimized to reduce the risk of infection in clients with premature rupture of membranes.
A client is receiving positive-pressure mechanical ventilation. Which of the following interventions should the nurse implement to prevent complications? (Select one that doesn't apply.)
- A. Elevate the head of the bed to at least 30°.
- B. Apply restraints if the client becomes agitated.
- C. Administer pantoprazole as prescribed.
- D. Reposition the endotracheal tube to the opposite side of the mouth daily.
Correct Answer: D
Rationale: Repositioning the endotracheal tube to the opposite side of the mouth daily is not a standard practice in preventing complications in a client receiving positive-pressure mechanical ventilation. This action may disrupt the secure placement of the endotracheal tube and increase the risk of complications. Elevating the head of the bed to at least 30° helps prevent aspiration and ventilator-associated pneumonia. Applying restraints if the client becomes agitated helps maintain the safety of the client by preventing self-extubation or accidental dislodgement of tubes. Administering pantoprazole as prescribed helps prevent stress ulcers, a common complication in critically ill patients on mechanical ventilation.
The nurse is educating a patient on what constitutes IPV. What is an example of an act of IPV?
- A. child endangerment
- B. stalking
- C. workplace harassment
- D. legal allegations
Correct Answer: B
Rationale: Stalking is a deliberate act where the perpetrator repeatedly follows, harasses, or intimidates the victim, which can instill fear or threaten safety. It is recognized as a specific form of intimate partner violence (IPV).