Nokea
The nurse is assessing a client immediately after an exploratory laparotomy. Which of the following nursing observations would relate to the complication of inTest inal obstruction?
- A. Protruding soft abdomen with frequent diarrhea.
- B. Distended abdomen with ascites.
- C. Minimal bowel sounds in all four quadrants.
- D. Distended abdomen with complaints of pain.
Correct Answer: D
Rationale: if an obstruction is present, the abdomen will become distended and painful
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The nurse is receiving reports about four pregnant women in active labor who have been admitted to the labor and delivery unit. Which of the following women should the nurse see FIRST?
- A. A 27-year-old nullipara at 38-weeks gestation, has a cervical dilatation of $2 \mathrm{~cm}$, fetus in transverse lie with baseline FHT of $155 \mathrm{bpm}$.
- B. A 32-year-old multipara at term, cervical dilatation of $8 \mathrm{~cm}$, fetus in a vertex presentation with the presenting part at +2 station.
- C. A 22-year-old nullipara at term, cervical dilatation of $10 \mathrm{~cm}, 100 \%$ effaced, fetus presenting as left occiput posterior with short-term variability of the FHT at 3-5 beats.
- D. A 34-year-old multipara at 37-weeks gestation, has intact amniotic membranes, cervical dilatation of $3 \mathrm{~cm}$, and fetus in a frank breech presentation with the presenting part at 0 station.
Correct Answer: B
Rationale: The multipara at 8 cm dilatation is in advanced labor and likely to deliver soon, making her the priority. Options A, C, and D are less urgent: transverse lie needs monitoring, nullipara at 10 cm has a longer second stage, and breech at 3 cm is early.
The nurse is transporting a mother and her newborn upon discharge from the hospital. When the nurse is assisting the mother and newborn into the car, the nurse notes that the car is equipped with a front-facing car seat that is in the front seat of the car. Which action is most appropriate for the nurse?
- A. Position the infant in the car seat as positioned.
- B. Explain that a rear-facing car seat is necessary and offer to lend the family a car seat from the hospital for the trip home.
- C. Tell the mother that holding the infant is safer than putting the infant in a front-facing car seat.
- D. Place the car seat in the back seat and position the infant appropriately.
Correct Answer: B
Rationale: Infants require rear-facing car seats in the back seat for safety. Offering a hospital car seat ensures proper transport safety.
When a client is having a general tonic clonic seizure, the nurse should
- A. Hold the client's arms at their side
- B. Place the client on their side
- C. Insert a padded tongue blade in client's mouth
- D. Elevate the head of the bed
Correct Answer: B
Rationale: Place the client on their side. This position maintains a patent airway and prevents aspiration.
Which of the following provides the best evidence that the nursing interventions to deal with a client’s self-care deficit in relation to feeding have been effective?
- A. The client eats at least one-half of all meals and drinks a minimum of 2,000 mL/day.
- B. The client’s dentures have been replaced, and he is able to chew.
- C. The client will eat without verbalizing suspicions when a particular nurse sits with him.
- D. The client appears to have increased energy to complete grooming activities.
Correct Answer: A
Rationale: Eating half of meals and drinking 2,000 mL/day is a concrete measure of adequate nutrition, indicating effective interventions. Options B, C, and D are less direct: dentures aid chewing but don’t ensure intake, suspicions suggest unresolved issues, and grooming energy is unrelated.
The client is being admitted for surgery. During the admission assessment, the client states that she usually has 8 to 10 alcoholic drinks a day. How should the nurse reply?
- A. What type of alcohol do you drink?
- B. How long have you been drinking alcohol?
- C. When was your last drink?
- D. Why do you drink so much?
Correct Answer: C
Rationale: Admitting to 8 to 10 alcoholic drinks a day is suggestive of alcoholism. It is important to know when the client last had a drink of alcohol in order to anticipate the onset of withdrawal symptoms. The type of alcohol the client drinks, how long the client has been drinking, and why the client drinks are not the key issues. The key issue is when to anticipate withdrawal symptoms.