Nokea
The nurse is caring for a client in her third trimester of pregnancy. The nurse is MOST concerned by which of the following assessments?
- A. The client complains of epigastric pain.
- B. The client complains of shortness of breath.
- C. The client states she has increased rectal pressure.
- D. The client has gained of 33 pounds during her pregnancy.
Correct Answer: A
Rationale: is usually indicative of an impending convulsion
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The nurse is caring for a 22-year-old woman who is completing the first stage of labor. The woman's husband is at her side and has been coaching her according to exercises they learned at natural childbirth classes. Suddenly the woman begins to shake and screams, 'I can't stand this anymore!' The nurse should encourage the husband to
- A. instruct his wife to use shallow respirations during the contractions.
- B. offer his wife ice chips or sips of water to distract her from the pain.
- C. stroke his wife's abdomen between contractions.
- D. review with his wife the breathing pattern needed at each stage of labor.
Correct Answer: A
Rationale: entering transition phase of first stage of labor, slow shallow breaths needed (pant breathing)
The home care nurse instructs the wife of a client about how to perform a wet-to-dry abdominal dressing for her husband with an infected abdominal incision. The nurse should intervene in which of the following situations?
- A. The wife wets the old dressing with sterile saline before removing it.
- B. The wife covers the wound with wet, sterile 4 × 4s.
- C. The wife irrigates the wound with hydrogen peroxide using a bulb syringe.
- D. The wife uses Montgomery straps to secure the dressing.
Correct Answer: A
Rationale: contraindicated, remove dry so wound debris and necrotic tissue are removed with old dressing
The nurse is caring for a 74-year-old man with type I diabetes. The client is scheduled for cataract surgery under general anesthesia at 9 AM. The man usually receives 30 units of NPH and 10 units of regular insulin each morning at 7 AM. At 7 AM the morning of surgery, the nurse would expect to take which of the following actions?
- A. hold the morning dose of NPH and regular insulin and monitor the blood glucose.
- B. give half the morning dose of NPH insulin along with the regular insulin and monitor the blood glucose when the client returns from surgery.
- C. give the full dose of NPH and regular insulin and monitor the blood glucose every 2 to 4 hours.
- D. give the full dose of regular insulin but hold the NPH insulin and monitor the blood glucose until the client goes to surgery.
Correct Answer: A
Rationale: usually use sliding scale with regular insulin based on blood glucose readings
The nurse is caring for a client with a history of peptic ulcer disease who is receiving omeprazole (Prilosec) 20 mg PO daily. Which of the following client statements would be of GREATest concern to the nurse?
- A. I have a headache once in a while.
- B. I feel bloated after meals.
- C. I have black, tarry stools.
- D. I take my medication with breakfast.
Correct Answer: C
Rationale: Black, tarry stools suggest gastroinTest inal bleeding, a serious complication in peptic ulcer disease requiring immediate evaluation. Options A, B, and D are less concerning: headaches are nonspecific, bloating is common, and taking omeprazole with food is acceptable.
A patient is returned to his room following an appendectomy. The nurse notices a large amount of serosanguineous drainage on the dressing. It is MOST important for the nurse to obtain an answer to which of the following questions?
- A. Were there any intraoperative complications?
- B. Has the dressing been changed?
- C. Why didn't the recovery room nurse report any drainage?
- D. Was a tissue drain placed during surgery?
Correct Answer: D
Rationale: drain is frequently placed during surgery to prevent accumulation in wound, dressing should be reinforced