Nokea
The initial assessment of a newborn reveals a chest circumference of 34 cm and an abdominal circumference of 31 cm. The chest is asymmetrical and breath sounds are diminished on the left side. The nurse should give priority to:
- A. Providing supplemental oxygen by a ventilated mask
- B. Performing auscultation of the abdomen for the presence of active bowel sounds
- C. Inserting a nasogastric tube to check for esophageal patency
- D. Positioning on the left side with head and chest elevated
Correct Answer: A
Rationale: Diminished breath sounds and chest asymmetry suggest a respiratory issue, such as pneumothorax, requiring immediate supplemental oxygen.
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A 38-year-old woman, mother of two, has a mastectomy for breast cancer. When she returns to the physician’s office a month later for a routine check-up, the nurse asks the client how she has been. Which of the following responses, if made by the client to the nurse, indicates that the client is experiencing a normal reaction to the surgery?
- A. I have been helping my family deal with their feelings about the surgery.
- B. I have been having difficulty coping with the surgery and cry frequently.
- C. I have been unable to leave the house or talk to my friends about the surgery.
- D. I am doing just great since the surgery and have gone back to work at my job.
Correct Answer: B
Rationale: normal reaction one month later
A client in the family planning clinic asks the nurse about the most likely time for her to conceive. The nurse explains that conception is most likely to occur when:
- A. Estrogen levels are low.
- B. Lutenizing hormone is high.
- C. The endometrial lining is thin.
- D. The progesterone level is low.
Correct Answer: B
Rationale: A surge in luteinizing hormone triggers ovulation, the time when conception is most likely.
The nurse enters a client's room and finds him lying on the floor. The client says to the nurse, 'I fell because I was trying to go to the bathroom and no one answered my call light.' Which of the following actions by the nurse are correct? Select all that apply.
- A. assist the client back to bed
- B. complete an incident report
- C. notify the health care provider
- D. assess the client for any injuries
- E. document in the medical record that the client fell
Correct Answer: A,B,C,D,E
Rationale: All actions are appropriate: assist the client safely, assess for injuries, notify the provider, complete an incident report, and document the fall to ensure proper care and follow-up.
A neonate has severe congenital abnormalities that make death imminent, and the NICU team believes that further attempts at treatment or feeding are not warranted and that palliative care only should be provided. When speaking with the parents about this, which of the following is the best approach?
- A. Tell the parents that the team suggests that all food and treatment will be withheld.
- B. Tell the parents that the team suggests a change in care plan to focus on comfort measures.
- C. Tell the parents that any further efforts at treatment are futile as the infant is dying.
- D. Tell the parents that the best thing is to let nature take its course.
Correct Answer: B
Rationale: Focusing on comfort measures (B) communicates compassionately that palliative care prioritizes the neonate's comfort, aligning with the parents' emotional needs. Withholding food/treatment (A) is harsh, futility (C) is blunt, and letting nature take its course (D) lacks clarity.
The nurse is caring for a client with a history of schizophrenia, alcohol abuse, bipolar disorder, and noncompliance with treatment and medications. The client has also been arrested in the past for violent behavior. Which action by the nurse is the most important when caring for a potentially violent client?
- A. treat the client with courtesy and respect
- B. always maintain an open pathway to the door
- C. be sure the client swallows his pills and does not 'cheek' them
- D. ask permission from the client before drawing blood or performing other invasive procedures
Correct Answer: B
Rationale: Maintaining an open pathway to the door ensures the nurse’s safety if the client becomes violent, prioritizing personal safety.