Nokea
The client is admitted with a diagnosis of abruptio placenta. Which diagnostic test is most likely to be ordered?
- A. Ultrasound
- B. Fetal heart monitoring
- C. Both A and B
- D. Neither A nor B
Correct Answer: C
Rationale: Ultrasound can confirm placental separation in abruptio placenta and fetal heart monitoring assesses for distress due to hypoxia. Both tests are critical for diagnosis and management.
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The nurse is caring for a client with a diagnosis of abruptio placenta. Which intervention is most appropriate?
- A. Monitor fetal heart tones
- B. Administer tocolytics
- C. Place the client in Trendelenburg position
- D. Administer antibiotics
Correct Answer: A
Rationale: Abruptio placenta can cause fetal hypoxia making fetal heart tone monitoring critical to assess fetal well-being. Tocolytics are contraindicated Trendelenburg may worsen bleeding and antibiotics are not indicated unless infection is present.
The nurse is assessing a trauma client in the emergency room when she notes a penetrating abdominal wound with exposed viscera. The nurse should:
- A. Apply a clean dressing to protect the wound.
- B. Cover the exposed viscera with a sterile saline gauze.
- C. Gently replace the abdominal contents.
- D. Cover the area with a petroleum gauze.
Correct Answer: B
Rationale: Exposed viscera should be covered with sterile saline-soaked gauze to keep them moist and prevent infection until surgical repair. Replacing contents or using non-sterile/petroleum dressings is unsafe.
A client with a history of testicular cancer is admitted with complaints of back pain. The nurse should give priority to:
- A. Monitoring for metastasis
- B. Administering pain medication
- C. Monitoring blood pressure
- D. Administering chemotherapy
Correct Answer: A
Rationale: Back pain in testicular cancer may indicate metastasis to retroperitoneal lymph nodes, so monitoring for metastasis is the priority.
The intensive care unit is full and the emergency room just called to report that a client with suspected carbon monoxide poisoning has arrived. Which clinical manifestation would the nurse expect if carbon monoxide poisoning has occurred?
- A. Pulse oximetry reading of 80%
- B. Expiratory stridor and nasal flaring
- C. Cherry red color to the mucous membranes
- D. Presence of carbonaceous particles in the sputum
Correct Answer: C
Rationale: Carbon monoxide binds hemoglobin, forming carboxyhemoglobin, causing cherry red mucous membranes. Pulse oximetry (A) is unreliable, stridor (B) suggests obstruction, and carbonaceous particles (D) indicate smoke inhalation.
The nurse is caring for a client with a history of asthma who is receiving Albuterol (Proventil). The nurse should monitor the client for:
- A. Tachycardia
- B. Hypotension
- C. Hypokalemia
- D. Hyperglycemia
Correct Answer: A
Rationale: Albuterol, a beta-agonist, commonly causes tachycardia as a side effect due to sympathetic stimulation. Hypotension, hypokalemia, and hyperglycemia are less frequent.