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The nurse is caring for an obstetrical client in early labor. After the rupture of membranes, the nurse should give priority to:
- A. Applying an internal monitor
- B. Assessing fetal heart tones
- C. Assisting with epidural anesthesia
- D. Inserting a Foley catheter
Correct Answer: B
Rationale: Assessing fetal heart tones is critical after rupture of membranes to detect fetal distress, such as cord compression.
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The nurse is caring for a client who has just returned from surgery for an ascending colostomy. The nurse plans to include reinforcement teaching for the client and spouse. Which statements should the nurse include in the teaching? Select all that apply.
- A. The colostomy will begin functioning within 24 hours.
- B. A large amount of bleeding may be present at the stoma site.
- C. The first stools will be liquid and will gradually become more formed.
- D. A healthy stoma is reddish-pink and moist and protrudes about 2 cm from the abdominal wall.
Correct Answer: C,D
Rationale: A healthy stoma is reddish-pink, moist, and protrudes slightly (D). Initial stools are liquid, becoming formed over time (C). Function typically starts in 2-5 days, not 24 hours (A), and significant bleeding (B) is abnormal.
The nurse is caring for a client hospitalized with a facial stroke. Which diet selection would be suited to the client?
- A. Roast beef sandwich, potato chips, pickle spear, iced tea
- B. Split pea soup, mashed potatoes, pudding, milk
- C. Tomato soup, cheese toast, Jello, coffee
- D. Hamburger, baked beans, fruit cup, iced tea
Correct Answer: B
Rationale: Soft foods like split pea soup, mashed potatoes, and pudding are easier to swallow for a client with a facial stroke, reducing the risk of aspiration.
The nurse caring for a client with a closed head injury obtains an intracranial pressure (ICP) reading of 17 mmHg. The nurse recognizes that:
- A. The ICP is elevated and the doctor should be notified.
- B. The ICP is normal; therefore, no further action is needed.
- C. The ICP is low and the client needs additional IV fluids.
- D. The ICP reading is not as reliable as the Glascow coma scale.
Correct Answer: A
Rationale: An ICP of 17 mmHg is elevated (normal is 7-15 mmHg), indicating increased intracranial pressure, which requires immediate notification of the physician.
A client with schizophrenia is started on Zyprexa (olanzapine). Three weeks later, the client develops severe muscle rigidity and elevated temperature. The nurse should give priority to:
- A. Withholding all morning medications
- B. Ordering a CBC and CPK
- C. Administering prescribed anti-Parkinsonian medication
- D. Transferring the client to a medical unit
Correct Answer: D
Rationale: Severe muscle rigidity and fever suggest neuroleptic malignant syndrome (NMS), a medical emergency requiring immediate transfer to a medical unit for treatment.
The nurse is caring for a child with Down syndrome. Which characteristics are commonly found in the child with Down syndrome?
- A. Fragile bones, blue sclera, and brittle teeth
- B. Epicanthal folds, broad hands, and transpalmar creases
- C. Low posterior hairline, webbed neck, and short stature
- D. Developmental regression and cherry-red macula
Correct Answer: B
Rationale: Down syndrome is characterized by epicanthal folds, broad hands, and transpalmar creases.