Nokea
The nurse is assessing a client at 11 weeks gestation. The first day of the client's last menstrual period was September 7. Which of the following findings should the nurse expect to obtain?
- A. reports feeling fetal movement
- B. reports increased urinary frequency
- C. fundal height of 24 cm above the symphysis pubis
- D. estimated delivery date of June 14 using the Naegele rule
- E. fetal heart tones detectable via Doppler ultrasound device
Correct Answer: B,D,E
Rationale: At 11 weeks, increased urinary frequency (B) is expected due to hormonal changes. The Naegele rule (LMP + 1 year - 3 months + 7 days) gives June 14 (D). Fetal heart tones are detectable by Doppler (E). Fetal movement (A) is felt later (16-20 weeks), and fundal height of 24 cm (C) occurs around 24 weeks.
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The unlicensed assistive personnel (UAP) reports to the nurse that during rounds a client has recently become pale. What is the nurse's first action?
- A. Activate the facility's emergency response system
- B. Ask the UAP to obtain a full set of vital signs
- C. Check on the client to collect further data
- D. Immediately notify the health care provider
Correct Answer: C
Rationale: Assessing the client directly (C) confirms the report and guides next steps. Activating emergency response (A), delegating vitals (B), or notifying the provider (D) is premature without assessment.
When reviewing the chart of a client with long standing lung disease, the nurse should pay close attention to the results of which pulmonary function test?
- A. Residual volume
- B. Total lung capacity
- C. FEV1/FVC ratio
- D. Functional residual capacity
Correct Answer: C
Rationale: The FEV1/FVC ratio indicates disease progression. As COPD worsens, the ratio of FEV1 to FVC becomes smaller. Answers A and B reflect loss of elastic recoil due to narrowing and obstruction of the airway. Answer D is increased in clients with obstructive bronchitis.
A nurse is observing a nursing student reinforce teaching to a client on how to take sucralfate. Which statement made by the student would require intervention by the nurse?
- A. Take this in the morning 1 hour before breakfast.
- B. Take this with your other stomach medications.
- C. Take your heart medication 2 hours after sucralfate.
- D. You might experience constipation while taking this.
Correct Answer: B
Rationale: Sucralfate (B) should not be taken with other stomach medications, as it forms a protective barrier, reducing their absorption. Timing (A, C) and constipation (D) are correct.
The nurse in the pediatric clinic is planning to reinforce postoperative teaching to parents. The nurse should talk with the parent of which child first?
- A. 2-year-old with bilateral tympanostomy tubes who has a small piece of plastic in the right outer ear
- B. 4-year-old post adenotonsillectomy who is now reporting ear pain
- C. 6-year-old with strep throat who needs a note to return to school 24 hours after starting antibiotics
- D. 7-year-old 5 days post tonsillectomy who wants to return to soccer practice tomorrow
Correct Answer: A
Rationale: A foreign object in the ear (A) poses an immediate risk of injury or infection, requiring urgent attention. Ear pain post-adenotonsillectomy (B) is common and less urgent. School clearance (C) and returning to sports (D) are non-emergent.
The nurse receives the handoff of care report on four clients. Which client should the nurse see first?
- A. Client reporting incisional pain of 8 on a scale of 0-10 with a respiratory rate of 25/min who had a right pneumonectomy 12 hours ago
- B. Client with a left pleural effusion who has crackles, absent breath sounds in the left base, and an SpO2 of 94% on room air
- C. Client with a temperature of 100.4 F (38 C) and a respiratory rate of 12/min who had a small bowel resection 1 day ago
- D. Client with pneumonia who has a temperature of 97.6 F (36.4 C), has an SpO2 of 93% on 4 L/min supplemental oxygen, and is becoming restless
Correct Answer: D
Rationale: Restlessness in a pneumonia client with low SpO2 (D) suggests worsening hypoxia, requiring immediate assessment. Severe pain (A) is urgent but stable. Pleural effusion (B) and fever (C) are less critical.