Nokea
The nurse is monitoring a client who is in active labor with a cervical dilation of 6 cm. Which finding requires intervention by the nurse?
- A. Contraction duration of 95 seconds
- B. Contraction frequency of every 3 minutes
- C. Contraction intensity of 45 mm Hg
- D. Uterine resting tone of 10 mm Hg
Correct Answer: A
Rationale: Contraction duration of 95 seconds (A) is too long and may reduce fetal oxygenation, requiring intervention. Frequency (B), intensity (C), and resting tone (D) are within normal limits.
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The nurse observes a certified nursing assistant (CNA) moving a client up in bed. Which action by the nursing assistant indicates a need for more instruction in how to move a client?
- A. Using a pull sheet
- B. Asking another nursing assistant to help
- C. Lowering the head of the bed
- D. Pulling the client by the shoulders
Correct Answer: D
Rationale: Pulling by the shoulders risks injury to the client's skin and joints. Using a pull sheet, getting help, and lowering the bed are correct techniques to ensure safety.
A 13-month-old child is admitted to the pediatric unit with diarrhea and vomiting. The mother tells the nurse that she is worried because her son does not yet walk. She says her other children walked at eight and nine months and asks what could be wrong with this child. How should the nurse respond?
- A. All babies are different. It is not abnormal that the baby is not yet walking.'
- B. The baby should be walking. I'll let the doctor know he is behind developmentally.'
- C. Your son is probably enjoying being the baby and is not eager to grow up and walk.'
- D. Walking requires complex coordination. Your son is probably just a little slow to develop this. Don't worry.'
Correct Answer: A
Rationale: Walking typically occurs between 9-18 months; at 13 months, not walking is within normal variation, reassuring the mother without dismissing concerns.
The nurse is providing care to a client with posttraumatic stress disorder following a terrorist attack at the client's place of worship. The client says, 'I'm just so worried all the time. I will never be safe again!' What is the priority nursing action?
- A. Acknowledge the client's feelings
- B. Assess the client's support system
- C. Encourage the client to talk about the trauma
- D. Offer the client a PRN sleep medication
Correct Answer: A
Rationale: Acknowledging feelings (A) builds trust and validates the client's experience, making it the priority. Assessing support (B), discussing trauma (C), or offering medication (D) are secondary.
The nurse is reinforcing teaching about home administration of sublingual nitroglycerin tablets to a client with stable angina. Which client statement indicates the need for further teaching?
- A. I can take 1 tablet every 5 minutes, up to 3 times, for chest pain.'
- B. I should call 911 if my chest pain isn't relieved by nitroglycerin.'
- C. I will call my doctor's office if I start experiencing chest pain at rest.'
- D. I will keep one bottle of nitroglycerin in the house and one in the car.'
Correct Answer: D
Rationale: Keeping nitroglycerin in a car (D) risks exposure to heat, reducing efficacy, requiring further teaching. Other statements (A, B, C) are correct.
The nurse is caring for a client with leukemia who is receiving the drug doxorubicin (Adriamycin). Which, if occurred, would be reported to the charge nurse immediately due to the toxic effects of this drug?
- A. Rales and distended neck veins
- B. Red discoloration of the urine and an output of 75 ml the previous hour
- C. Nausea and vomiting
- D. Elevated BUN and dry flaky skin
Correct Answer: A
Rationale: This drug can cause cardiotoxicity exhibited by changes in the ECG and congestive heart failure. Rales and distended neck veins are clinical manifestations of congestive heart failure, so answer A is correct. A reddish discoloration to the urine is a harmless side effect, so answer B is incorrect. An elevated BUN and dry, flaky skin are not specific to this drug, so answers C and D are incorrect.