Nokea
The nurse is caring for a client with a history of venous insufficiency. Which of the following interventions is most appropriate?
- A. Encourage prolonged standing.
- B. Apply compression stockings.
- C. Keep the legs in a dependent position.
- D. Limit fluid intake.
Correct Answer: B
Rationale: Compression stockings improve venous return and reduce swelling in venous insufficiency.
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A client with a history of type 1 diabetes is admitted with hyperglycemia. The nurse should include which of the following in the plan of care?
- A. Administer regular insulin as prescribed.
- B. Restrict fluid intake.
- C. Encourage a high-carbohydrate diet.
- D. Administer glucagon.
Correct Answer: A
Rationale: Regular insulin corrects hyperglycemia in type 1 diabetes.
Which procedure should be avoided in order to help prevent the transmission of the human immunodeficiency virus (HIV) from a positive pregnant mother to her fetus during the intrapartum period?
- A. Cesarean birth
- B. Epidural anesthesia
- C. External fetal heart rate monitoring
- D. Direct (internal) fetal heart rate monitoring
Correct Answer: D
Rationale: Health care professionals must use caution during the intrapartal period to reduce the risk of the transmission of HIV to the fetus. Any procedure that exposes blood or body fluids from the mother to the fetus should be avoided. Direct (internal) fetal monitoring is a procedure that may expose the fetus to maternal blood or body fluids and therefore should be avoided. None of the remaining options are invasive measures that place the fetus at risk in the intrapartum period.
A client diagnosed with chronic kidney disease (CKD) has learned about managing diet and fluid restriction between dialysis treatments. The nurse determines that the client is compliant with the therapeutic regimen when the assessment demonstrates a weight gain of no more than how many kilograms between hemodialysis treatments?
- A. 0.5 to 0.9 kg
- B. 1 to 1.5 kg
- C. 2 to 4 kg
- D. 5 to 6 kg
Correct Answer: B
Rationale: The primary health care provider will prescribe the amount of fluid that the client is allowed to gain between dialysis treatments, but usually a limit of 1 to 1.5 kg of weight gain between dialysis treatments helps prevent hypotension that tends to occur during dialysis with the removal of larger fluid loads. The nurse determines that the client is compliant with fluid restriction if this weight gain is not exceeded.
A client demonstrating unstable ventricular tachycardia (VT) loses consciousness and becomes pulseless after an initial treatment with a dose of lidocaine intravenously. Which item should the nurse caring for the client immediately obtain?
- A. A pacemaker
- B. A defibrillator
- C. A second dose of lidocaine
- D. An electrocardiogram machine
Correct Answer: B
Rationale: For the client with VT who becomes pulseless, the primary health care provider or qualified advanced cardiac life support personnel immediately defibrillate the client. In the absence of this equipment, cardiopulmonary resuscitation is initiated immediately. None of the remaining options are items that are needed immediately to manage this situation.
The nurse is preparing to administer a measles, mumps, and rubella (MMR) vaccine to a 15-month-old. Where should the nurse administer the injection?
- A. Deltoid muscle
- B. Vastus lateralis muscle
- C. Gluteal muscle
- D. Subcutaneous tissue of the abdomen
Correct Answer: B
Rationale: The vastus lateralis is the preferred site for intramuscular vaccines like MMR in toddlers due to adequate muscle mass and low risk of nerve damage.