Nokea
The nurse is developing goals for the postpartum client who is at risk for uterine infection. Which goal is most appropriate for this client?
- A. The client will verbalize a reduction of pain.
- B. The client will report how to treat an infection.
- C. The client will be able to identify measures to prevent infection.
- D. The client will identify the presence of Braxton Hicks contractions.
Correct Answer: C
Rationale: The uterus is theoretically sterile during pregnancy until the membranes rupture. However, it is capable of being invaded by pathogens after membrane rupture. The reduction of pain and Braxton Hicks contractions that occur during pregnancy are unrelated to the subject of infection. Reporting the treatment of infection indicates that an infection is present. Preventing an infection is a goal for the client who is at risk for infection.
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The nurse in an ambulatory clinic administers a tuberculin skin test to a client on a Monday. When should the nurse tell the client to return to the clinic to have the results read?
- A. Thursday or Friday
- B. The following Monday
- C. Tuesday or Wednesday
- D. Wednesday or Thursday
Correct Answer: D
Rationale: The tuberculin skin test for tuberculosis is read in 48 to 72 hours; therefore, the client should return to the clinic on Wednesday or Thursday.
The nurse teaches a client diagnosed with a spinal cord injury about measures to prevent autonomic hyperreflexia. Which statement by the client indicates the need for additional teaching?
- A. It is best if I avoid tight clothing and lumpy bedclothes.
- B. I should watch for headache, congestion, and flushed skin.
- C. Signs/symptoms I should watch for include fever and chest pain.
- D. I need to pay close attention to how frequently my bowels move.
Correct Answer: C
Rationale: Autonomic hyperreflexia generally occurs in a client with a spinal cord injury after the period of spinal shock resolves. It occurs with injuries above T6 and cervical injuries. Signs/symptoms of autonomic hyperreflexia include headache, congestion, flushed skin above the level of injury and cold skin below it, diaphoresis, nausea, and anxiety. Fever and chest pain are not associated with this condition.
The labor and delivery nurse notes that the health care provider has rated a newborn's Apgar score as 9. The nurse understands which to be true regarding Apgar scores?
- A. The optimum score is 10.
- B. A baby with poor activity would rate a 1 in that area.
- C. The highest score that each factor may receive is 3.
- D. Scores are obtained 5 minutes after birth and repeated 5 minutes later.
Correct Answer: A
Rationale: The optimal Apgar score is 10. Each factor scores 0-2, and scores are taken at 1 and 5 minutes post-birth.
A client weighs 165 pounds (75 kg) at admission. During hospitalization, the nurse determines that the client is maintaining adequate nutritional status if the client's weight is how many pounds?
- A. 153 pounds (69.5 kg)
- B. 155 pounds (70.4 kg)
- C. 157 pounds (71.3 kg)
- D. 160 pounds (72.7 kg)
Correct Answer: D
Rationale: Adequate nutritional status is maintained if the client's weight remains within 5 pounds of the baseline (165 pounds), so 160 to 165 pounds is acceptable. Weights below 160 pounds indicate significant loss, suggesting inadequate nutrition.
A normal, healthy 35-year-old male client visits the doctor's office for a routine annual physical. When auscultating between the first and second interspaces on the anterior chest, the nurse anticipates which type of breath sound?
- A. bronchovesicular
- B. vesicular
- C. bronchial
- D. tracheal
Correct Answer: A
Rationale: Bronchovesicular sounds are expected between the first and second interspaces, where major bronchi and alveoli are near.