Nokea
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: After rupture of membranes, assessing fetal heart tones is critical to detect distress, such as cord prolapse. Monitoring, anesthesia, and catheterization are secondary priorities.
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The nurse is caring for a client with a history of diverticulitis. Which meal selection indicates that the client understands the dietary teaching?
- A. Roast beef, mashed potatoes, and spinach
- B. Baked chicken, rice, and an apple
- C. Ham sandwich, chips, and whole wheat bread
- D. Spaghetti with meat sauce and garlic bread
Correct Answer: B
Rationale: Clients with diverticulitis should follow a low-residue diet during flare-ups to reduce bowel irritation. Baked chicken, rice, and an apple are low in fiber and suitable. The other options contain high-fiber or irritating foods (e.g., spinach, whole wheat, garlic).
When planning care for a 9-year-old client, the nurse uses which of the most effective means of helping siblings cope with their feelings about a brother who is terminally ill?
- A. Open discussion and understanding
- B. Play-acting out feelings in different roles
- C. Storytelling
- D. Drawing pictures
Correct Answer: B
Rationale: When dealing with grief, siblings are usually most comfortable initially with open discussion. Assuming different roles allows children to act out their feelings without fear of reprisals and to gain insight and control. This method may be helpful, but having the child take an active part through role playing is more effective. This technique may be helpful, but being an active participant through role playing is more effective.
A client with a history of a stroke is being taught to use a cane. The nurse should teach the client to:
- A. Hold the cane in the strong hand
- B. Advance the cane with the strong leg
- C. Use the cane on the weak side
- D. Lean heavily on the cane while walking
Correct Answer: C
Rationale: The cane should be used on the weak side to support the affected leg, improving balance and gait post-stroke. Holding it in the strong hand or advancing with the strong leg is incorrect.
Which meal selection is most appropriate for a patient with iron deficiency anemia?
- A. Roast turkey,gelatin,green beans
- B. Chicken salad, sandwich,coleslaw,French fries
- C. Egg salad on wheat bread,carrot sticks ,spinach and kale salad
- D. Pork chop,mashed potatoes,green peas
Correct Answer: C
Rationale: Spinach and kale are rich in iron ,which is essential for correcting iron deficiency anemia. The other meal options do not contain significant iron-rich foods making them less appropriate for this condition.
A 2-year-old toddler is hospitalized with epiglottitis. In assessing the toddler, the nurse would expect to find:
- A. A productive cough
- B. Expiratory stridor
- C. Drooling
- D. Crackles in the lower lobes
Correct Answer: C
Rationale: A productive cough is not associated with epiglottitis. Children with epiglottitis seldom have expiratory stridor. Inspiratory stridor is more common due to edema of the supraglottic tissues. Because of difficulty with swallowing, drooling often accompanies epiglottitis. Crackles are not heard in the lower lobes with epiglottitis because the infection is usually confined to the supraglottic structures.