Nokea
The nurse is caring for a client in the outpatient clinic who is four months pregnant.
- A. Which symptom reported by a four-month pregnant client requires immediate follow-up?
- B. Intermittent nausea in the morning.
- C. A white vaginal discharge.
- D. Breast tenderness bilaterally.
- E. Feeling the need to void more frequently.
Correct Answer: A
Rationale: Intermittent nausea in the second trimester (four months) is abnormal, as morning sickness typically resolves by the end of the first trimester, and may indicate complications like hyperemesis gravidarum or other issues requiring evaluation. Vaginal discharge, breast tenderness, and frequent urination are normal pregnancy symptoms.
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A patient before administration of morphine sulfate 8 mg IM q 3-4 hours for pain PRN.
In which of the following situations should the nurse consider withholding the medication until further assessment is done?
- A. The patient complains of acute pain from a second-degree burn affecting the lower left leg.
- B. The patient's blood pressure is 140/90, pulse is 90, and respiration is 28.
- C. The patient's level of consciousness fluctuates from alert to lethargic.
- D. The patient exhibits restlessness, anxiety, and cold, clammy skin.
Correct Answer: C
Rationale: Strategy: Determine the significance of each answer choice and how it relates to morphine. (1) morphine used for moderate to severe pain, medication should be given (2) BP slightly elevated, respirations elevated, may be the result of pain, medication should be given (3) correct-morphine depresses CNS, especially respiratory center in medulla (4) may be the result of pain
A client's Salem sump tube (nasogastric).
Which of the following findings would indicate to the nurse that a client's Salem sump tube (nasogastric) was functioning effectively?
- A. Fluctuation of the fluid level in the water seal chamber.
- B. Active bubbling in the suction bottle.
- C. The presence of a hissing sound from the blue lumen tube.
- D. A pressure of 25 mm Hg in the esophageal balloon.
Correct Answer: C
Rationale: Strategy: Determine how each answer choice relates to a Salem sump tube. (1) Salem sump tube is not a water-sealed drainage system (2) associated with a water-sealed drainage system (3) correct-'hissing' sound is indicative that air is freely exiting the airway, purpose is to provide continuous steady suction without pulling gastric mucosa (4) is relevant to a Sengstaken-Blakemore tube
The nurse is providing instructions for a client with asthma who is sensitive to house dust-mites. Which information about prevention of asthma episodes would be the most helpful to include during the teaching?
- A. Change the pillow covers every month
- B. Wash bed linens in warm water with a cold rinse
- C. Wash and rinse the bed linens in hot water
- D. Use air filters in the furnace system
Correct Answer: C
Rationale: Wash and rinse the bed linens in hot water. For asthma clients sensitive to house dust-mites, washing bed linens in hot water above 130 degrees Fahrenheit is necessary to kill dust-mites.
A 7-year-old daughter weighs 50.25 lb (22.85 kg) and is 48 inches (121.7 cm) tall. The nurse notes that she has gained 2.5 pounds and has grown 3 inches in the past year.
Which of the following responses by the nurse is BEST?
- A. Your daughter's height and weight are within normal limits.'
- B. Your daughter's height is normal, but she needs to gain some weight.'
- C. Your daughter's height is normal, but she needs to lose some weight.'
- D. Your daughter's weight is normal, but she is shorter than normal.'
Correct Answer: A
Rationale: Strategy: 'BEST' indicates that you will have to discriminate between answers. The topic of the question is unstated. Read answer choice to obtain clues. (1) correct-between ages 6-12 grows about 2 in (5 cm)/year and gains 4.5-6.5 lb (2-3 kg)/year, at age 7 average 39-66.5 lb (17.7-30 kg) and 44-51 in (111.8-129.7 cm) (2) weight is within normal limits (3) weight is within normal limits (4) height is within normal limits
The nurse is preparing a client for a skin biopsy.
Which of the following client statements should the nurse report to the physician?
- A. I've been taking aspirin for my sore knees.'
- B. Using lotion has helped my dry skin.'
- C. I went to the tanning salon yesterday.'
- D. I had a big breakfast this morning.'
Correct Answer: A
Rationale: Strategy: Determine how the statements relate to skin biopsy. (1) correct-aspirin compounds can increase bleeding time and should not be taken prior to a surgical procedure (2) does not affect the accuracy or results of the biopsy (3) does not affect the accuracy or results of the biopsy (4) does not affect the accuracy or results of the biopsy