The nurse is assessing a client who states her last menstrual period was March 16, and she has missed one period. She reports episodes of nausea and vomiting. Pregnancy is confirmed by a urine test. What will the nurse calculate as the estimated date of delivery (EDD)?
- A. 8-Apr
- B. 15-Jan
- C. 11-Feb
- D. 23-Dec
Correct Answer: D
Rationale: December 23. Naegele's rule states: Add 7 days and subtract 3 months from the first day of the last regular menstrual period to calculate the estimated date of delivery.
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Hearing screening of prematurely born infants is an effective means of identifying disease and is an example of:
- A. primary prevention.
- B. secondary prevention.
- C. tertiary prevention.
- D. disability prevention.
Correct Answer: B
Rationale: The three levels of prevention address disease and disability across all phases, from absence of disease and at risk for disease, to preventing further impairment. Hearing impairment associated with prematurity cannot be prevented by screening, but identifying the infants with hearing loss might prevent sequelae and further impairment by allowing early intervention.
Prior to checking a fingerstick blood glucose level, the nurse checks the identification band of the newly admitted client transferred from another facility. The nurse notes that the name and birth date are correct but that the band has the logo from another facility. Which is the best action by the nurse?
- A. Ask the UAP to obtain a new band while the nurse performs the planned procedure.
- B. Stop and replace the band with the current facility band that has the client identifiers.
- C. Ask the client to state his or her name and birth date and to verify them against the band.
- D. Leave the band in place; a name band from one facility can be used in another facility.
Correct Answer: B
Rationale: Replacing the band ensures the medical record number matches the current facility, preventing errors during procedures.
After an explosion at a factory one of the employees approaches the nurse and says 'I am an unlicensed assistive personnel (UAP) at the local hospital.' Which of these tasks should the nurse assign first to this worker who wants to help care for the wounded workers?
- A. Get temperatures
- B. Take blood pressure
- C. Palpate pulses
- D. Check alertness
Correct Answer: C
Rationale: Palpate pulses. The heart rates would indicate if the client is in shock or has potential for shock. If the pulses could not be palpated, those clients would need to be seen first.
The nurse is teaching the parents of a 3 month-old infant about nutrition. What is the main source of fluids for an infant until about 12 months of age?
- A. Formula or breast milk
- B. Dilute nonfat dry milk
- C. Warmed fruit juice
- D. Fluoridated tap water
Correct Answer: A
Rationale: Formula or breast milk. Formula or breast milk are the perfect food and source of nutrients and liquids up to 1 year of age.
The charge nurse is planning assignments on a medical unit. Which client should be assigned to the practical nurse (PN)?
- A. Test a stool specimen for occult blood
- B. Assist with the ambulation of a client with a chest tube system
- C. Irrigate and redress a leg wound
- D. Admit a client from the emergency room
Correct Answer: C
Rationale: The PN is a licensed provider and can perform this complex task. Irrigating and redressing a leg wound requires clinical skills appropriate for a PN, whereas the other tasks are either simpler or require an RN.