Nokea
The nurse is measuring the uterine fundal height of a client at 36 weeks gestation lying in a supine position. The client suddenly reports dizziness, and the nurse observes pallor and damp, cool skin. What should the nurse do first?
- A. Alert the supervising registered nurse
- B. Check the client's blood pressure and pulse
- C. Listen to the fetal heart rate
- D. Turn the client to a lateral position
Correct Answer: D
Rationale: Symptoms suggest supine hypotensive syndrome; turning the client to a lateral position relieves uterine pressure on the vena cava, improving blood flow.
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The nurse is evaluating the security of the client's tracheostomy ties. Which of the following methods is used to assess for tie tightness?
- A. The nurse places one finger between the tie and the neck.
- B. The tracheostomy can be pulled slightly away from the neck.
- C. There are no tie marks present.
- D. The nurse uses a Velcro fastener instead of a tie.
Correct Answer: A
Rationale: Placing one finger between the tie and neck ensures ties are secure but not overly tight, preventing tissue damage or airway obstruction.
The nurse is performing an assessment on a child with severe airway obstruction. Which finding would the nurse anticipate?
- A. Retractions in the intercostal tissues of the thorax
- B. Chest pain aggravated by respiratory movement
- C. Cyanosis and mottling of the skin
- D. Rapid, shallow respirations
Correct Answer: A
Rationale: Retractions in the intercostal tissues of the thorax. Severe airway obstruction causes extreme intercostal retractions due to increased respiratory effort.
The nurse is caring for a client who has a C6 spinal cord injury. He complains of blurred vision and a severe headache. His blood pressure is 210/140. What action should the nurse take initially?
- A. Check for bladder distention
- B. Place in Trendelenburg position
- C. Administer PRN pain medication
- D. Continue to monitor blood pressure
Correct Answer: A
Rationale: Symptoms and hypertension suggest autonomic dysreflexia, often triggered by bladder distention in spinal cord injury. Checking and relieving distention is the initial action.
A client has had a positive reaction to purified protein derivative (PPD). The client asks the nurse what this means. The nurse should indicate that the client has
- A. active tuberculosis
- B. been exposed to mycobacterium tuberculosis
- C. never had tuberculosis
- D. never been infected with mycobacterium tuberculosis
Correct Answer: B
Rationale: The PPD skin test is used to determine the presence of tuberculosis antibodies and a positive result indicates that the person has been exposed to mycobacterium tuberculosis. Additional tests are needed to determine if active tuberculosis is present.
The oncoming nurse is receiving report on 4 clients. Which should be the priority assessment?
- A. Client who had a carotid endarterectomy that day with a blood pressure of 160/88 mm Hg
- B. Client who is 1 day post bowel resection with absent bowel sounds
- C. Client with a pulse of 109/min who has a history of atrial fibrillation
- D. Client with pancreatitis whose total parenteral nutrition is almost finished
Correct Answer: A
Rationale: Elevated blood pressure (160/88 mm Hg) post-carotid endarterectomy risks hematoma or stroke, making it the priority. Other conditions are less urgent.