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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A client is admitted with the diagnosis of pulmonary embolism. While taking a history, the client tells the nurse he was admitted for the same thing twice before, the last time just 3 months ago. The nurse would anticipate the provider ordering
- A. pulmonary embolectomy
- B. vena caval interruption
- C. increasing the Coumadin therapy to an INR of 3-4
- D. thrombolytic therapy
Correct Answer: B
Rationale: vena caval interruption. Clients with contraindications to Heparin, recurrent PE or those with complications related to the medical therapy may require vena caval interruption by the placement of a filter device in the inferior vena cava. A filter can be placed transvenously to trap clots before they travel to the pulmonary circulation.
A female client is admitted for a breast biopsy. She says, tearfully to the nurse, 'If this turns out to be cancer and I have to have my breast removed, my partner will never come near me.' The nurse's best response would be which of these statements?
- A. I hear you saying that you have a fear for the loss of love.'
- B. You sound concerned that your partner will reject you.'
- C. Are you wondering about the effects on your sexuality?'
- D. Are you worried that the surgery will lead to changes?'
Correct Answer: D
Rationale: This is a general lead-in type of response that encourages further discussion without focusing on an area that the nurse, but possibly not the client, feels is a problem.
A client is scheduled for an elective laparoscopic prostatectomy in the morning. The practical nurse should notify the registered nurse about which of the following assessment data as soon as possible before surgery?
- A. INR level
- B. platelet count
- C. hemoglobin and hematocrit levels
- D. temperature 100.4 F (38 C) with cough
Correct Answer: D
Rationale: A temperature of 100.4 F with cough suggests a possible infection, which could contraindicate surgery due to increased risk of complications.
The pediatric nurse receives report on 4 clients. Which client should the nurse see first?
- A. A 2-month-old awaiting evaluation for possible hip dislocation; parents are at the bedside
- B. A 6-year-old just returned from a bronchoscopy; a parent is at the bedside
- C. A 7-year-old just returned from a non-contrast abdominal CT scan; no parents are at the bedside
- D. An 11-year-old scheduled for ear surgery today, no parents are at the bedside
Correct Answer: B
Rationale: The 6-year-old post-bronchoscopy is at risk for airway complications and requires immediate assessment.
The daughter of a 78-year-old woman asks the nurse why her mother is giving away some of her belongings to her children and grandchildren. What should the nurse include when responding?
- A. Older adults usually become more generous.
- B. It is normal for older adults to think about and prepare for their own death.
- C. Her mother probably does not trust her children to divide her things appropriately.
- D. Her mother is probably thinking about suicide.
Correct Answer: B
Rationale: Giving away belongings reflects preparation for death, a normal developmental task in older adults achieving ego integrity. Generosity, distrust, or suicide are less likely.