Nokea
The med-surge nurse receives a report on a client who is legally blind. Which action by the nurse would be most likely to reduce this client's anxiety?
- A. Assign the client to a private room.
- B. Orient the client to their room.
- C. Request for a sitter to be assigned.
- D. Instruct the UAP to check on the client frequently.
Correct Answer: B
Rationale: Orienting a legally blind client to their room reduces anxiety by promoting safety and familiarity.
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The emergency department nurse is caring for a client with sudden onset of edema of the lips and acute shortness of breath following a bee sting. The nurse knows that the first-line medication for this presentation is:
- A. Oral diphenhydramine
- B. Nebulized albuterol
- C. Oral prednisone
- D. Parenteral epinephrine
Correct Answer: D
Rationale: Anaphylaxis from a bee sting requires immediate parenteral epinephrine to reverse airway edema and respiratory distress.
The following scenario applies to the next 1 items
The nurse cares for a primigravida in labor.
Item 1 of 1
Nurses’ Note
1940: The client is alert and fully oriented. The client is talkative and has an anxious affect. Cervical dilation of 6 cm with 100% effacement. No vaginal discharge was noted. Contractions are noted every 2-3 minutes, lasting 40-60 seconds with moderate intensity.
Fetal Heart Rate
Continuous fetal heart monitoring (FHR): 130-145/minute with normal variability.
Vital Signs
• Oral Temperature 98o F (37o C)
• Heart rate 84/minute
• Respirations 20/minute
• Blood pressure 131/72 mm Hg
• Oxygen saturation 95% on room air
The nurse reviews the client's clinical data.
Drag a word from the choices below to complete the sentence.
Based on the clinical data, the client is in the ___ stage of labor. Specifically, the ___ phase.
- A. first
- B. second
- C. third
- D. fourth
- E. latent
- F. active
- G. transition
Correct Answer: A, F
Rationale: Cervical dilation of 6 cm with 100% effacement and frequent contractions indicate the first stage of labor, active phase.
The nurse is providing teaching to a client experiencing chronic constipation. Which of the following meals would be the best choice for this client in order to promote a bowel movement?
- A. steak and a baked potato
- B. brussels sprouts and a whole grain roll
- C. white rice with chicken
- D. ham sandwich with tomato soup
Correct Answer: B
Rationale: Brussels sprouts and whole grain rolls are high in fiber, promoting bowel movements.
The nurse has attended a continuing education presentation about acid-base imbalances. It would indicate a correct understanding of the conference if the nurse identifies which of the following conditions may cause the ABG in the exhibit.
- A. Five-day history of severe diarrhea
- B. Hyperemesis gravidarum
- C. End-stage renal disease (ESRD)
- D. Diabetic ketoacidosis (DKA)
- E. Chronic obstructive pulmonary disease (COPD)
- F. Hyperglycemic hyperosmolar nonketotic syndrome (HHNS)
Correct Answer: A, B, D, F
Rationale: Severe diarrhea, hyperemesis gravidarum, DKA, and HHNS can cause metabolic acidosis, as indicated by a low pH and low bicarbonate on ABG.
The nurse is caring for a child diagnosed with Tetralogy of Fallot. The client has had multiple hypercyanotic episodes (tet spells). The nurse anticipates that the physician will prescribe
- A. morphine sulfate
- B. adenosine
- C. diltiazem
- D. atropine sulfate
Correct Answer: A
Rationale: Morphine sulfate is used to manage tet spells by reducing oxygen demand and relaxing the child.