Nokea
The FHR pattern in a laboring client begins to show early decelerations. The nurse would best respond by:
- A. Notifying the physician
- B. Changing the client to the left lateral position
- C. Continuing to monitor the FHR closely
- D. Administering O2 at 8 L/min via face mask
Correct Answer: C
Rationale: Early decelerations are reassuring and do not warrant notification of the physician. Because early decelerations is a reassuring pattern, it would not be necessary to change the client's position. Early decelerations warrant the continuation of close FHR monitoring to distinguish them from more ominous signs. O2 is not warranted in this situation, but it is warranted in situations involving variable and/or late decelerations.
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Which action by the healthcare worker indicates a need for further teaching?
- A. The nursing assistant ambulates the elderly client using a gait belt.
- B. The nurse wears goggles while performing a venipuncture.
- C. The nurse washes his hands after changing a dressing.
- D. The nurse wears gloves to monitor the IV infusion rate.
Correct Answer: D
Rationale: Wearing gloves to monitor an IV infusion rate is unnecessary unless contact with bodily fluids is anticipated indicating a need for further teaching on standard precautions. The other actions are appropriate safety measures.
A family by court order undergoes treatment by a family therapist for child abuse. The nurse, who is the child's case manager knows that treatment has been effective when:
- A. The child is removed from the home and placed in foster care
- B. The child's parents identify the ways in which he is different from the rest of the family
- C. The child's father is arrested for child abuse
- D. The child's parents can identify appropriate behaviors for children in his age group
Correct Answer: D
Rationale: Removing an abused child from the home and placement in a foster home are not the desired outcome of treatment. Children who are perceived as 'different' from the rest of the family are more likely to be abused. Although legal action may be taken against abusive parents, it is not an indicator of an effective treatment program. Identification of age-appropriate behaviors is essential to the role of parents, because misunderstanding children's normal developmental needs often contributes to abuse or neglect.
An 80-year-old widow is living with her son and daughter-in-law. The home health nurse has been making weekly visits to draw blood for a prothrombin time test. The client is taking 5 mg of coumadin per day. She appears more debilitated, and bruises are noted on her face. Elder abuse is suspected. Which of the following are signs of persons who are at risk for abusing an elderly person?
- A. A family member who is having marital problems and is regularly abusing alcohol
- B. A person with adequate communication and coping skills who is employed by the family
- C. A friend of the family who wants to help but is minimally competent
- D. A lifelong friend of the client who is often confused
Correct Answer: A
Rationale: This answer is correct. Two risk factors are identified in this answer. This answer is incorrect. Persons at risk tend to lack communication skills and effective coping patterns. This answer is incorrect. Persons at risk are usually family members or those reluctant to provide care. This answer is incorrect. This individual has a vested interest in providing care.
A client had abdominal surgery this morning. The nurse notices that there is a small amount of bloody drainage on his surgical dressing. The nurse would document this as what type of drainage?
- A. Serosanguinous
- B. Purulent
- C. Sanguinous
- D. Catarrhal
Correct Answer: C
Rationale: Drainage from a surgical incision is initially sanguinous, proceeding to serosanguinous, and then to serous.
A physician tells the nurse that he wants to orally intubate a client with a No. 8 endotracheal tube. The finding of normal breath sounds on the right side of the chest and diminished, distant breath sounds on the left side of the chest of a newly intubated client is probably due to:
- A. A left hemothorax
- B. A right hemothorax
- C. Intubation of the right mainstem bronchus
- D. An inadequate mechanical ventilator
Correct Answer: C
Rationale: The right mainstem bronchus is most frequently intubated in error because the angle of the right mainstem bronchus is very small as compared with that of the left mainstem bronchus. Because ventilation is only occurring on the right side, the nurse would auscultate diminished and distant breath sounds on the left.