Nokea
The nurse is caring for a client who is in the first stage of labor and is reporting intense back pain with contractions. The fetal position is determined to be right occiput posterior. Which of the following actions should the nurse take?
- A. Place the client in the supine position
- B. Apply counterpressure to the client's sacrum during contractions
- C. Encourage the client to remain in bed
- D. Request that the nurse anesthetist administer epidural anesthesia
Correct Answer: B
Rationale: For back pain in labor with a right occiput posterior position, applying counterpressure to the sacrum relieves discomfort. Supine position worsens pain, bed rest limits mobility, and epidural is not the first intervention.
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At a well baby clinic the nurse is assigned to assess an 8 month-old child. Which of these developmental achievements would the nurse anticipate that the child would be able to perform?
- A. Say 2 words
- B. Pull up to stand
- C. Sit without support
- D. Drink from a cup
Correct Answer: C
Rationale: Sit without support. This is a typical developmental milestone for an 8-month-old.
The client has contact dermatitis from poison ivy. Which statement, if made by the client, indicates that he understands how to care for his condition?
- A. A hot bath should make the itching go away.'
- B. I will use a good strong soap when I wash the affected areas.'
- C. A cool wet cloth to the area should help.'
- D. Wearing wool socks will help my itchy feet.'
Correct Answer: C
Rationale: A cool wet cloth soothes itching and inflammation in contact dermatitis. Hot baths, strong soaps, or wool exacerbate irritation.
The doctor has prescribed imipramine (Tofranil) for an elderly client with endogenous depression. The nurse should give priority to assessing the client's:
- A. Fluid intake
- B. Cardiac status
- C. Respiratory effort
- D. Urinary output
Correct Answer: B
Rationale: Imipramine, a tricyclic antidepressant, can cause cardiac arrhythmias, especially in the elderly, making cardiac status assessment a priority.
The nurse is participating in a staff presentation to review risk factors for skin cancer. Which of the following risk factors should the nurse include? Select all that apply.
- A. Family history of skin cancer
- B. High number of moles
- C. History of severe adolescent acne
- D. Immunosuppressant medication use
- E. Outdoor occupation
Correct Answer: A,B,D,E
Rationale: Risk factors for skin cancer include family history , high number of moles , immunosuppressant use increasing susceptibility, and outdoor occupation due to UV exposure. Severe acne is not a direct risk factor unless associated with specific treatments like radiation.
The nurse is caring for a client who has a prescription for albuterol 5 mg via nebulizer every 4 hours. The nurse has albuterol 2.5 mg/3 mL available. How many mL should the nurse administer to the client with each dose? Record your answer using a whole number.
Correct Answer: 6 mL/dose
Rationale: Albuterol 5 mg is needed, with 2.5 mg/3 mL available. Thus, 5 mg ÷ 2.5 mg × 3 mL = 6 mL per dose.