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The nurse caring for a client with myasthenia gravis is reviewing the nursing care plan. Which is recognized as the priority nursing diagnosis?
- A. Risk for injury
- B. Acute pain
- C. Ineffective airway clearance
- D. Impaired mobility
Correct Answer: C
Rationale: Clients with myasthenia gravis have problems with the muscular activity of breathing. Answers A, B, and D are not the priority, so they are wrong.
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The nurse is caring for a client with spontaneous rupture of membranes. The nurse notes a loop of umbilical cord protruding from the vagina. Which of the following actions should the nurse take?
- A. Apply suprapubic pressure
- B. Perform Leopold maneuvers
- C. Perform the McRoberts maneuver
- D. Assist the client to the knee-chest position
Correct Answer: D
Rationale: Umbilical cord prolapse is an emergency requiring the knee-chest position to relieve cord compression. Suprapubic pressure and McRoberts are for shoulder dystocia, and Leopold maneuvers are for fetal positioning assessment.
The nurse reinforces discharge instructions to a client who was hospitalized for deep venous thrombosis that has now resolved. Which instructions should the nurse include to prevent reoccurrence? Select all that apply.
- A. Do not travel by car or airplane for at least 3-4 weeks
- B. Drink plenty of fluids daily and limit caffeine and alcohol intake
- C. Elevate legs on a footstool when sitting and dorsiflex the feet often
- D. Resume the walking or swimming exercise program as soon as possible after getting home
- E. Sit in a cross-legged yoga position for 5-10 minutes as this benefits circulation
Correct Answer: B,C,D
Rationale: To prevent DVT recurrence: stay hydrated to reduce blood viscosity, elevate legs and dorsiflex to promote venous return, and resume exercise to enhance circulation. Travel restrictions are not absolute post-resolution, and cross-legged sitting impedes venous flow.
The nurse is participating in a staff presentation to review risk factors for skin cancer. Which of the following risk factors should the nurse include? Select all that apply.
- A. Family history of skin cancer
- B. High number of moles
- C. History of severe adolescent acne
- D. Immunosuppressant medication use
- E. Outdoor occupation
Correct Answer: A,B,D,E
Rationale: Risk factors for skin cancer include family history , high number of moles , immunosuppressant use increasing susceptibility, and outdoor occupation due to UV exposure. Severe acne is not a direct risk factor unless associated with specific treatments like radiation.
Four clients arrive in the urgent care clinic. Which does the nurse anticipate to be the priority for intervention?
- A. Child who is confused and irritable and whose parent claims 2 glyburide pills are missing
- B. Child with an abscess on the buttock that is red, swollen, and warm to the touch
- C. Child with immune thrombocytopenia who fell off a bike and reports shoulder pain
- D. Child with low-grade fever, barking cough, and runny nose who has mild retractions
Correct Answer: A
Rationale: The child who is confused and irritable with missing glyburide pills suggests a potential hypoglycemic emergency due to sulfonylurea overdose, which requires immediate intervention to prevent severe complications like seizures or coma.
The doctor has ordered the insertion of an NG tube to determine the extent of gastric bleeding in a client with a gastric ulcer. To facilitate the insertion of the NG tube, the nurse should:
- A. Place the NG tube in warm water prior to insertion.
- B. Place the client in a supine position.
- C. Ask the client to swallow as the tube is advanced.
- D. Ask the client to hyper-extend his neck as the nurse begins to insert the tube.
Correct Answer: C
Rationale: Asking the client to swallow helps guide the NG tube into the esophagus and stomach, facilitating insertion.