Nokea
The nurse is caring for an ambulatory client who has a new order for continuous cardiac monitoring via a portable unit. It would require follow-up if the nurse
- A. verifies that gel is present on each electrode and is not dried out
- B. cleanses and dries the skin before placing the electrodes on the client
- C. clips excessive hair off the client before applying the electrodes
- D. places one electrode each on the client's upper and lower extremities
Correct Answer: D
Rationale: Placing electrodes on extremities (D) is incorrect for cardiac monitoring, which requires chest placement. Verifying gel (A), cleansing skin (B), and clipping hair (C) are appropriate.
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The nurse is talking with a client with major depressive disorder who has been taking paroxetine for the past 3 weeks. Which of the following statements by the client would require immediate follow-up?
- A. I have had a decreased appetite lately.'
- B. I still feel depressed even though I have more energy.'
- C. I sometimes have difficulty falling asleep at night.'
- D. I have had a decreased interest in sexual activity recently.'
Correct Answer: B
Rationale: Persistent depression with increased energy (B) may indicate rising suicide risk, requiring immediate follow-up. Appetite (A), sleep (C), and libido (D) changes are common side effects.
The client with hyperparathyroidism will exhibit signs of:
- A. Hypokalemia
- B. Hyponatremia
- C. Hypercalcemia
- D. Hyperphosphatemia
Correct Answer: C
Rationale: Hyperparathyroidism increases parathyroid hormone, causing hypercalcemia by mobilizing calcium from bones and increasing absorption. Hypokalemia , hyponatremia , and hyperphosphatemia are not typically associated.
A diabetic multigravida is scheduled for an amniocentesis at 32 weeks gestation to determine the L/S ratio and phosphatidyl glycerol level. The L/S ratio is 1:1 and the presence of phosphatidyl glycerol is noted. The nurse's assessment of this data is:
- A. The infant is at low risk for congenital anomalies.
- B. The infant is at high risk for intrauterine growth retardation.
- C. The infant is at high risk for respiratory distress syndrome.
- D. The infant is at high risk for birth trauma.
Correct Answer: C
Rationale: An L/S ratio of 1:1 and presence of phosphatidyl glycerol suggest immature lungs, indicating a high risk for respiratory distress syndrome, so C is correct. Answers A, B, and D are not directly related to these findings.
The nurse is beginning nutritional counseling/teaching with a pregnant woman. What is the initial step in this interaction?
- A. Teach her how to meet the needs of self and her family
- B. Explain the changes in diet necessary for pregnant women
- C. Question her understanding and use of the food pyramid
- D. Conduct a diet history to determine her normal eating routines
Correct Answer: D
Rationale: Assessment is always the first step in planning teaching for any client. A thorough and accurate history is essential for gathering the needed information.
The nurse is caring for a client who has a Clostridioides difficile infection. Which of the following infection control precautions should the nurse implement? Select all that apply.
- A. Apply sterile gloves before providing client care.
- B. Request that the client be placed in a private room.
- C. Use an alcohol-based hand sanitizer for hand hygiene.
- D. Wear a single-use, protective gown when providing client care.
- E. Ensure surgical masks are worn by staff members who enter the client's room.
Correct Answer: B, D
Rationale: A private room (B) and protective gown (D) are required for contact precautions. Sterile gloves (A) are unnecessary, alcohol-based sanitizer (C) is ineffective against C. difficile spores, and surgical masks (E) are not required.