Nokea
The nurse is caring for a client with cirrhosis of the liver with ascites. When instructing nursing assistants in the care of the client, the nurse should emphasize that the client
- A. Should remain on bed rest in a semi-Fowler's position
- B. Should alternate ambulation with bed rest with legs elevated
- C. May ambulate and sit in chair as tolerated
- D. May ambulate as tolerated and remain in semi-Fowlers position in bed
Correct Answer: B
Rationale: Should alternate ambulation with bed rest with legs elevated. Encourage alternating periods of ambulation and bed rest with legs elevated to mobilize edema and ascites.
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The nurse observes the certified nursing assistant doing all of the following. Which action needs correction?
- A. Changing the dressing of a client with an abdominal wound
- B. Asking a standing client to sit down while vital signs are taken
- C. Emptying a urine drainage bag from the tube at the bottom
- D. Changing water in the middle of a bed bath
Correct Answer: A
Rationale: Changing dressings requires nursing judgment and sterile technique, outside a CNA's scope. Other actions are within their role.
A 23-year-old woman in active labor.
The nurse observes the fetal heart monitor for a 23-year-old woman in active labor. The fetal heart tracing shows early fetal decelerations. The nurse is aware that this is
- A. a slowing early in the contraction, and is usually a normal finding.
- B. a slowing early in the contraction, and is usually an abnormal finding.
- C. a slowing at the peak of the contraction, and is usually a normal finding.
- D. a slowing at the peak of the contraction, and is usually an abnormal finding.
Correct Answer: A
Rationale: Strategy: Think about each answer choice. (1) correct-occurs in response to compression of fetal head, uniform shape corresponds to rise in intrauterine pressure as uterus contracts, does not indicate fetal distress (2) does not indicate fetal distress (3) slowing is early in the contraction (4) slowing is early in uterine contraction and is not abnormal
The nurse is caring for an adult who had a cervical laminectomy this morning. In addition to routine vital signs, what should the nurse assess because of the location of the surgery?
- A. Pedal pulses
- B. Hand grasps
- C. Radial pulse
- D. Urine output
Correct Answer: B
Rationale: Cervical laminectomy affects the cervical spine, which innervates upper extremities; assessing hand grasps evaluates neurological function. Pedal pulses, radial pulse, and urine output are unrelated.
The nurse is teaching a client with a new diagnosis of rheumatoid arthritis about methotrexate (Rheumatrex). Which of the following instructions should the nurse include?
- A. Take the medication with grapefruit juice.
- B. Avoid folic acid supplements.
- C. Report any fever or sore throat.
- D. Stop the medication if joint pain decreases.
Correct Answer: C
Rationale: Methotrexate can cause bone marrow suppression; fever or sore throat may indicate infection, requiring reporting. Options A, B, and D are incorrect.
The nurse is caring for a client with a history of polycystic kidney disease.
- A. Which symptom is expected in a client with polycystic kidney disease?
- B. Chest pain and dyspnea.
- C. Flank pain and hematuria.
- D. Weight loss and fever.
- E. Numbness in the extremities.
Correct Answer: B
Rationale: Flank pain and hematuria are common in polycystic kidney disease due to cyst pressure and rupture. Chest pain, weight loss, and numbness are unrelated.