Nokea
The nurse is assessing the perineal changes of a woman in the second stage of labor. The nurse expects to see which of the following changes?
- A. Anterior-posterior slit.
- B. Oval opening.
- C. Circular shape.
- D. Crowning.
Correct Answer: D
Rationale: Crowning, when the fetal head is visible at the vaginal opening, is the expected perineal change in the second stage of labor, indicating imminent delivery.
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The nurse holds the gauze pledget against an I.M. injection site while removing the needle from the muscle. This technique helps to:
- A. Seal off the track left by the needle in the tissue.
- B. Speed the spread of the medication in the tissue.
- C. Avoid the discomfort of the needle pulling on the skin.
- D. Prevent organisms from entering the body through the skin puncture.
Correct Answer: A
Rationale: Holding gauze against the injection site prevents medication leakage along the needle track, ensuring proper drug absorption.
A client has been given a prescription for propantheline as adjunctive treatment for peptic ulcer disease. How should the nurse tell the client to take this medication?
- A. With meals
- B. With antacids
- C. Just after meals
- D. Thirty minutes before meals
Correct Answer: D
Rationale: Propantheline is an antimuscarinic anticholinergic medication that decreases gastrointestinal secretions. It should be administered 30 minutes before meals to reduce acid secretion before food intake stimulates gastric acid production. Administering with meals or just after meals would reduce its effectiveness, and taking it with antacids could interfere with its absorption.
The nurse is monitoring a client who has received antidysrhythmic therapy for the treatment of premature ventricular contractions (PVCs). Which observation in the PVCs would indicate to the nurse that this therapy is ineffective?
- A. Occur in pairs
- B. Be unifocal in appearance
- C. Be fewer than 6 per minute
- D. Fall after the end of the T wave
Correct Answer: A
Rationale: PVCs are considered dangerous when they are frequent (more than 6 per minute), occur in pairs or couplets, are multifocal (multiform), or fall on the T wave.
A child is brought to the emergency department after being bitten on the arm by a neighborhood dog. Which is the priority question for the nurse to ask the parent of the child?
- A. How old is the dog?
- B. Does the dog have a history of biting?
- C. Are the child's immunizations up-to-date?
- D. Did the dog have all of its recommended shots?
Correct Answer: C
Rationale: When a bite occurs, the injury site of the bite should be cleansed carefully and the child should be given tetanus prophylaxis if immunizations are not up-to-date. The remaining options identify information that may have to be obtained, but are not the priority questions. Additionally the mother may not have the answers to these questions.
The home care nurse visits a client who started wandering around at 10:00 pm each evening and got out of the house for the first time last night. The family asks for help. Which therapeutic response should the nurse make to the family?
- A. What prevented her from leaving the house in the past?
- B. You cannot handle this alone because she could get hurt.
- C. I think you need to consider a nursing home immediately.
- D. This is a common problem known as sundowner's syndrome.
Correct Answer: A
Rationale: The nurse responds to the family by assessing the situation and collecting additional data regarding the change in the client's behavior. The best response focuses on the family's problem so that the nurse can help develop potential strategies. Option 2 is giving advice. Option 3 is histrionic, invalidates the family's attempt to manage the client's care, and potentially causes resentment. Option 4 provides the nurse's conclusion based on an incomplete assessment; other factors may be causing confusion.