Nokea
The nurse assists with data collection during a routine prenatal visit for a client at 36 weeks gestation. Which statement by the client is most concerning to the nurse?
- A. I'm not sleeping as well due to cramps in my calves at night.
- B. I've noticed fewer kicking movements as the baby grows bigger.
- C. Over the last few weeks, I've been unable to wear any of my shoes.
- D. Sometimes I feel short of breath after walking up a flight of stairs.
Correct Answer: B
Rationale: Decreased fetal movement may indicate fetal distress and requires immediate evaluation.
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The nurse is observing continuous cardiac monitoring for assigned clients. Which of the following cardiac rhythms would immediate follow-up?
Correct Answer: C
Rationale: Ventricular fibrillation (VF) is a lethal dyshythmia characterized by disorganized electrical activity in the heart ventricles. Because
of this erratic electrical activity, the heart muscles lose the ability to contract, resulting in loss of blood flow and pulse (ie, cardiac
arrest). Nurses who identify a client with VF should immediately check the pulse, start CPR, and prepare the client for defibrillation
The nurse finds a person unresponsive on the floor. What is the initial nursing action?
- A. Start chest compressions
- B. Assess respirations and pulse
- C. Place on a hard surface
- D. Start mouth-to-mouth breathing
Correct Answer: B
Rationale: Assessing respirations and pulse determines if CPR is needed, per ACLS guidelines. Compressions, positioning, or breathing are premature without confirming unresponsiveness and absence of pulse/breathing.
A nurse is discharging a client who is receiving lithium for treatment of a bipolar disorder. It is most important for the nurse to reinforce which instruction to the client?
- A. Avoid a high-potassium diet
- B. Exercise regularly and maintain a high-fiber diet
- C. Maintain oral hygiene
- D. Report excessive urination and increased thirst
Correct Answer: D
Rationale: Lithium can cause polyuria and polydipsia due to its effect on renal function. These symptoms may indicate lithium toxicity or diabetes insipidus, which require immediate medical attention.
A 2 month-old child has had a cleft lip repair. The selection of which restraint would require no further action by the charge nurse?
- A. Elbow
- B. Mummy
- C. Jacket
- D. Clove hitch
Correct Answer: A
Rationale: Elbow. The elbow restraint will prevent the child from touching the surgical site without hindering movement of other parts of the body.
The pediatric nurse is reinforcing education about medication administration to the parents of a 4-year-old client. Which statements made by the parents demonstrate correct understanding? Select all that apply.
- A. I can mix the medication in a bowl of my child's favorite cereal.
- B. I should give another dose if my child vomits after taking the medication.
- C. I should measure liquid medications using an oral syringe.
- D. I will encourage my child to help me as I prepare the medication.
- E. I will place my child in time-out if the medication is refused.
Correct Answer: C
Rationale: Using an oral syringe ensures accurate dosing. Mixing with food, redosing after vomiting, involving the child in preparation, or punishing refusal are inappropriate.