Nokea
The nurse is caring for a client in the second stage of labor. The fetal heart monitor shows late decelerations. The nurse should initially
- A. notify the physician
- B. encourage the client deep-breathe slowly
- C. reposition the client to a left side-lying position
- D. obtain a prescription for intravenous isotonic fluids
Correct Answer: C
Rationale: Repositioning to the left side-lying position improves placental perfusion, addressing late decelerations.
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The nurse is triaging a child with suspected impetigo. Which action should the nurse take?
- A. Initiate droplet precautions
- B. Set up a decontamination room
- C. Use a disposable blood pressure cuff
- D. Initiate contact precautions
- E. Apply sterile gloves while examining the client
Correct Answer: D, E
Rationale: Impetigo requires contact precautions and sterile gloves to prevent spread during examination.
The nurse is caring for a client who has developed retinal detachment. Which of the following actions should the nurse take first?
- A. Instruct the client to restrict activity
- B. Establish a vascular access device
- C. Review the client's current medications
- D. Educate the client about topical eye ointments
Correct Answer: A
Rationale: Restricting activity is the first priority to prevent further retinal damage.
The nurse is caring for a client with suspected placenta previa. The nurse anticipates an order for which diagnostic test to confirm this finding?
- A. Manual cervical exam
- B. Transvaginal ultrasound
- C. Contraction stress test
- D. Nonstress test
Correct Answer: B
Rationale: Transvaginal ultrasound is the safest and most accurate method to confirm placenta previa, avoiding risky manual exams.
The nurse is caring for a child immediately following a nephrectomy in the postanesthesia care unit (PACU). Which assessment should the nurse initially perform?
- A. pain level
- B. peripheral vascular access device
- C. surgical incision
- D. vital signs
Correct Answer: D
Rationale: Vital signs are the initial priority in the PACU to assess stability post-nephrectomy.
The nurse in the emergency department (ED) is caring for a 10-year-old client.
Item 5 of 5
Nurses' Notes
1322: 10-year-old client and his parents report an 8-day history of a brownish-raised lesion over the back of his left leg. The parents report that the size of the rash has increased. The parents report returning from a one-week camping trip three weeks ago. The parents deny efficacy with over-the-counter antihistamine creams. The client's parents deny that the child has had a fever but has felt 'warm' occasionally and endorsed an intermittent headache. They report an area of firmness in the child's groin. On assessment, there was an erythematous, raised, nonpainful, oval patch on the back of his left leg. This was an enlargement of an inguinal lymph node. The child is alert and fully oriented and denies any pain. Peripheral pulses palpable 2+. No cyanosis or edema in the extremities. Lung sounds clear bilaterally. The parents report that the child did not receive the seasonal influenza vaccine. He currently takes a multivitamin for iron deficiency anemia and was hospitalized one year ago for an appendectomy. The parents state that the child’s sibling had influenza one month ago. Vital signs: T 98.8°F (37.1°C); HR 78 beats/min; RR 16 breaths/min; BP 110/76 mm Hg. SpO2 97% on room air.
Progress Notes
1401: The client was evaluated. The rash is localized, raised, and appears like a bullseye. The client has inguinal lymphadenopathy. The client's recent camping trip supports the probability of a vector-borne illness—specifically, Lyme disease.
Orders
• laboratory tests: IgM and IgG antibodies
• doxycycline 100 mg capsule p.o. twice daily for fourteen days
• discharge client home
• follow-up with a primary care physician in two weeks
The nurse reviews and executes the physician's orders. Which of the following actions should the nurse take when performing venipuncture on a 10-year-old client?
- A. Identify the child by only checking their identification armband.
- B. Apply a cold compress to the area to promote vasodilation.
- C. Demonstrate the procedure using a stuffed animal.
- D. Allow the child to decide which arm they would like for the venipuncture.
- E. Ask the child if they want to help set up some equipment.
- F. Offer the child a sedative to help them relax before the procedure.
Correct Answer: C, D, E
Rationale: Demonstrating on a stuffed animal, allowing arm choice, and involving the child in setup reduce anxiety and promote cooperation. Cold compresses constrict vessels, and sedatives are not routinely offered.