Nokea
The nurse has attended a staff education program about the signs of pregnancy. Which of the following is considered a positive sign of pregnancy?
- A. Amenorrhea
- B. Uterine soufflé
- C. Positive pregnancy test
- D. Fetal heartbeat
Correct Answer: D
Rationale: Fetal heartbeat is a positive sign of pregnancy, as it directly confirms the presence of a fetus.
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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.
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 is performing a physical assessment on a newborn. The nurse assessed 3+ brachial pulses, cold and pale feet, decreased capillary refill time in the feet, and warm and pink hands. Which cardiac disease process do these assessment findings support?
- A. Tetralogy of Fallot (TOF)
- B. Hypoplastic left heart syndrome
- C. Coarctation of the aorta (COA)
- D. Transposition of the great arteries
Correct Answer: C
Rationale: These findings suggest coarctation of the aorta, with reduced lower extremity perfusion due to aortic narrowing.
The nurse in the emergency department (ED) is caring for a 64-year-old male client.
Item 4 of 6
Nurses' Notes
1742: Client arrives at the emergency department via emergency medical services (EMS). He was skiing and crashed into a post and fell to the ground. Ski patrol assessed the client, and the client was confused and had no memory of the crash. Ski patrol reports that he was wearing a helmet and had a loss of consciousness for an unknown amount of time. On assessment, the client was alert and oriented to place and time but did not recall the events leading up to hospitalization, specifically the ski crash. Client states, “My head really hurts and I'm dizzy.” Reporting aching pain rated 8/10 on the Numerical Pain Scale. Reddish contusion on the client's forehead. Pupils were 2+, equal, and sluggishly reactive to light. Glasgow Coma Scale 14. Nose is midline and symmetrical. His speech was clear and articulate. Full range of motion in all extremities observed. Clear lung fields bilaterally. Radial pulse 2+ and irregular. Normoactive bowel sounds in all quadrants. No abdominal distention or pain. Vital signs: T 97.8° F (36.6° C), P 85, RR 15, BP 124/82, pulse oximetry reading 98% on room air. The client has a medical history of essential hypertension, generalized anxiety disorder, atrial fibrillation, and chronic back pain.
Diagnostic Results
Head and Neck Computed Tomography (CT) Scan with Contrast
1831: Bilateral convexity subarachnoid hemorrhage over the right frontal lobe.
Laboratory Results
1849: Hemoglobin (Hgb) 14 g/dL [Male: 14-18 g/dL Female: 12-16 g/dL]
Hematocrit (Hct) 42% [Male: 42-52% Female: 37-47%]
International Normalized Ratio (INR) 3.8 [0.9-1.2]
Platelets 140,000 mm3 [150,000-400,00 mm3]
Home medications
• multivitamin (MVI) 1 tablet PO daily
• fluoxetine 20 mg PO daily
• biotin 100 mcg PO daily
• pantoprazole 40 mg PO daily
• warfarin 2.5 mg PO daily
• diltiazem controlled-release 120 mg PO daily
The nurse reviews the diagnostic and laboratory results. For each potential nursing intervention, click to specify whether the Nurses' Notes intervention is indicated or not indicated for the care of the client.
- A. obtain an order for serum type and screen
- B. obtain a prescription for protamine sulfate
- C. perform neurological assessments every 15 minutes
- D. obtain a prescription for andexanet
- E. obtain a prescription to transfuse platelets
- F. obtain a prescription for ketorolac
- G. monitor the client for signs and symptoms of increased intracranial pressure
Correct Answer: A, C, D, G (indicated); B, E, F (not indicated)
Rationale: Indicated: Serum type and screen for potential transfusion, frequent neurological assessments, andexanet for warfarin reversal, and monitoring for increased intracranial pressure due to subarachnoid hemorrhage. Not indicated: Protamine sulfate (for heparin, not warfarin), platelet transfusion (platelets mildly low), ketorolac (contraindicated due to bleeding risk).
The nurse is caring for a client who is edentulous. Which of the following diet orders should the nurse request from the healthcare provider?
- A. a low sodium diet
- B. a mechanical soft diet
- C. a renal diet
- D. a high-fiber diet
Correct Answer: B
Rationale: A mechanical soft diet is appropriate for an edentulous client to ensure safe chewing and swallowing.