Nokea
The nurse is caring for a client with a history of a tracheoesophageal fistula. The nurse should:
- A. Position the client flat in bed
- B. Suction the tracheostomy frequently
- C. Provide small, frequent feedings
- D. Restrict all oral intake
Correct Answer: D
Rationale: A tracheoesophageal fistula risks aspiration, requiring restricted oral intake until surgically repaired. Positioning, suctioning, and feedings are secondary or contraindicated.
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A primipara is assessed on arrival to the postpartum unit. The nurse finds her uterus to be boggy. The nurse's first action should be to:
- A. Call the physician
- B. Assess her vital signs
- C. Give the prescribed oxytocic drug
- D. Massage her fundus
Correct Answer: D
Rationale: The nurse should first implement independent and dependent measures to achieve uterine tone before calling the physician. Assessment of vital signs will not help to restore uterine atony, which is the priority need. Giving a prescribed oxytocic drug would be necessary if the uterus did not maintain tone with massage. Fundal massage generally restores uterine tone within a few moments and should be attempted first.
The nurse is caring for a client with a diagnosis of chorioamnionitis. Which diagnostic test is most likely to be ordered?
- A. Complete blood count
- B. Amniotic fluid analysis
- C. Both A and B
- D. Neither A nor B
Correct Answer: C
Rationale: Chorioamnionitis requires a complete blood count to assess for infection (e.g. elevated white blood cells) and amniotic fluid analysis to confirm infection. Both tests are commonly ordered.
Which term applies to the misconduct by a healthcare provider that results in harm to the patient?
- A. Negligence
- B. Tort
- C. Assault
- D. Malpractice
Correct Answer: D
Rationale: Malpractice refers to professional misconduct or negligence by a healthcare provider that causes harm to a patient. Negligence is a broader term tort is a civil wrong and assault involves intent to harm.
The nurse is preparing a 6-year-old child for an IV insertion. Which one of the following statements by the nurse is appropriate when preparing a child for a potentially painful procedure?
- A. Some say this feels like a pinch or a bug bite. You tell me what it feels like.
- B. This is going to hurt a lot; close your eyes and hold my hand.
- C. This is a terrible procedure, so don't look.
- D. This will hurt only a little; try to be a big boy.
Correct Answer: A
Rationale: Educating the child about the pain may lessen anxiety. The child should be prepared for a potentially painful procedure but avoid suggesting pain. The nurse should allow the child his own sensory perception and evaluation of the procedure. The nurse should avoid absolute descriptive statements and allow the child his own perception of the procedure. The nurse should avoid evaluative statements or descriptions and give the child control in describing his reactions. False statements regarding a painful procedure will cause a loss of trust between the child and the nurse.
The nurse is teaching a client with a history of lactose intolerance about dietary modifications. The nurse should tell the client to avoid:
- A. Dairy products
- B. High-fiber foods
- C. Lean meats
- D. Fresh fruits
Correct Answer: A
Rationale: Dairy products contain lactose, which causes gastrointestinal symptoms in lactose intolerance, so they should be avoided.