Nokea
The nurse is caring for a client admitted to labor and delivery. The nurse is aware that the infant is in distress if she notes:
- A. Contractions every three minutes
- B. Absent variability
- C. Fetal heart tone accelerations with movement
- D. Fetal heart tone 120-130 bpm
Correct Answer: B
Rationale: Absent variability on the fetal monitor indicates fetal distress, suggesting compromised oxygenation.
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How many hours of activity per day are necessary to prevent disuse syndrome with muscle atrophy and joint contracture?
- A. 6 hours
- B. 4 hours
- C. 2 hours
- D. 1 hour
Correct Answer: C
Rationale: Approximately 2 hours of activity daily (C), including range-of-motion exercises or ambulation, helps prevent disuse syndrome, muscle atrophy, and joint contractures in immobilized clients.
The nurse is working with a nursing student to administer an enema solution to a client. The client states she feels painful cramping. The nurse should intervene by
- A. squeezing the enema bag so the flow rate is faster.
- B. explaining to the client that this is a normal feeling and continuing with the enema.
- C. clamping the tube for 1 minute and then starting the enema at a slower rate.
- D. discontinuing the enema until the provider can order a PRN pain medication.
Correct Answer: C
Rationale: Painful cramping during an enema suggests too-rapid administration. Clamping briefly and slowing the rate reduces discomfort.
A client develops mastitis in the postpartum period. Which of the following instructions does the nurse anticipate when notifying the physician? Select all that apply.
- A. Antibiotics for 7 to 10 days.
- B. Opioid analgesia.
- C. Alternating hot and cold compresses to relieve the pain.
- D. Discontinuation of breastfeeding.
- E. Continuation of breastfeeding.
Correct Answer: A,C,E
Rationale: Mastitis is typically treated with antibiotics (A) for 7-10 days to address the infection. Alternating hot and cold compresses (C) can help relieve pain and reduce inflammation. Continuation of breastfeeding (E) is encouraged to promote milk flow and prevent further complications, unless contraindicated. Opioid analgesia (B) is not typically required, and discontinuation of breastfeeding (D) is not recommended as it may worsen the condition.
The nurse is preparing to assist with a lumbar puncture for a client with suspected meningitis. Which of the following positions should the nurse place the client in?
- A. Supine with the head elevated.
- B. Prone with the head turned to one side.
- C. Side-lying with knees flexed to the chest.
- D. Sitting with the back arched.
Correct Answer: C
Rationale: side-lying with knees flexed to the chest maximizes spinal flexion, facilitating access to the subarachnoid space
The nurse is developing a plan for bowel and bladder retraining for a client with paraplegia. The primary goal of a bowel and bladder retraining program is:
- A. Optimal restoration of the client's elimination pattern
- B. Restoration of the client's neurosensory function
- C. Prevention of complications from impaired elimination
- D. Promotion of a positive body image
Correct Answer: C
Rationale: The primary goal is to prevent complications like infections or skin breakdown by establishing effective bowel and bladder management.