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The nurse is doing a digital removal of stool for a client with a large fecal impaction resulting from opioid use when the client feels faint, and assessment of vital signs shows a marked decrease in pulse. Which of the following is the most likely reason for the change in pulse rate?
- A. Stimulation of the vagus nerve
- B. Onset of shock
- C. Internal bleeding
- D. Anxiety
Correct Answer: A
Rationale: Digital stool removal can stimulate the vagus nerve (A), causing bradycardia and faintness. Shock (B), bleeding (C), or anxiety (D) are less likely.
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The nurse is observing a student nurse administer a client's medications via a nasogastric (NG) tube. The nurse understands that the student nurse needs further teach if the student nurse performs which action?
- A. aspirates and checks the residual
- B. places client in the semi-Fowler's position
- C. verifies that the medications may be given via NG tube
- D. stops the tube feeding before medication administration
- E. flushes tubing with 15-30 cc of water after administering meds
- F. None
- G. all the above
Correct Answer: F
Rationale: All listed actions are correct for NG medication administration. No intervention is needed.
A client is admitted to the labor and delivery unit. The nurse performs a vaginal exam and determines that the client's cervix is 5cm dilated with 75% effacement. Based on the nurse's assessment the client is in which phase of labor?
- A. Active
- B. Latent
- C. Transition
- D. Early
Correct Answer: A
Rationale: A cervix dilated to 5 cm with 75% effacement indicates the active phase of labor.
Which one of the following infants needs a further assessment of growth?
- A. 4-month-old: birth weight 7 lb, 6 oz; current weight 14 lb, 4 oz
- B. 2-week-old: birth weight 6 lb, 10 oz; current weight 6 lb, 12 oz
- C. 6-month-old: birth weight 8 lb, 8 oz; current weight 15 lb
- D. 2-month-old: birth weight 7 lb, 2 oz; current weight 9 lb, 6 oz
Correct Answer: B
Rationale: The 2-week-old has only gained 2 oz since birth, which is inadequate (normal is 0.5-1 oz/day), indicating a need for growth assessment.
A client with a diagnosis of HPV is at risk for which of the following?
- A. Hodgkin's lymphoma
- B. Cervical cancer
- C. Multiple myeloma
- D. Ovarian cancer
Correct Answer: B
Rationale: Human papillomavirus (HPV) is a major risk factor for cervical cancer, particularly high-risk strains like HPV-16 and HPV-18.
Which breakfast selection by a client with osteoporosis indicates that the client understands the dietary management of the disease?
- A. Scrambled eggs, toast, and coffee
- B. Bran muffin with margarine
- C. Granola bar and half of a grapefruit
- D. Bagel with jam and skim milk
Correct Answer: D
Rationale: Skim milk is high in calcium, essential for bone health in osteoporosis. The other options lack significant calcium sources, making them less appropriate.