Nokea
The nurse is monitoring the contractions of a woman in labor. A contraction is recorded as beginning at 10:00 A.M and ending at 10:01 A.M. Another begins at 10:15 A.M. What is the frequency of the contractions?
- A. 14 minutes
- B. 10 minutes
- C. 15 minutes
- D. 9 minutes
Correct Answer: C
Rationale: 15 minutes. Frequency is measured from the start of one contraction to the start of the next.
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The client is being treated with intravenous Vancomycin for MRSA when the nurse notes redness of the client's neck and chest. Place in ordered sequence the actions to be taken by the nurse:
- A. Call the doctor.
- B. Stop the IV infusion of Vancomycin.
- C. Administer Benadryl as ordered.
- D. Take the vital signs.
Correct Answer: B,D,C,A
Rationale: Redness suggests an allergic reaction or 'red man syndrome' from rapid vancomycin infusion. The nurse should: stop the infusion to prevent further reaction, take vital signs to assess severity, administer Benadryl if ordered, and call the doctor for further orders.
John H is a 66-year-old man with a history of heavy smoking presented himself to the ER due to difficulty breathing of 2 years duration. Mr. H was also diagnosed with effusion of the right lung. He is now scheduled for chest tube insertion.
Appropriate patient teaching when the chest tube is removed:
- A. Instruct the patient take deep breath and hold it during removal.
- B. Inform the patient that this is not a painful procedure.
- C. Ensure that the site is covered with a loose, dry dressing.
- D. Expect tachypnea after the removal.
Correct Answer: A
Rationale: Holding a deep breath during removal prevents air entry into the pleural space.
A child who has recently been diagnosed with cystic fibrosis (CF) is being assessed by a pediatric clinic nurse. Which finding of this disease would the nurse not expect to see at this time?
- A. Positive sweat test
- B. Bulky greasy stools
- C. Moist, productive cough
- D. Meconium ileus
Correct Answer: C
Rationale: Moist, productive cough. Option C is a later sign. Noisy respirations and a dry non-productive cough are commonly the first of the respiratory signs to appear in a newly diagnosed client with CF. The other options are the earliest findings. CF is an inherited (genetic) condition affecting the cells that produce mucus, sweat, saliva and digestive juices. Normally, these secretions are thin and slippery, but in CF, a defective gene causes the secretions to become thick and sticky. Instead of acting as a lubricant, the secretions plug up tubes, ducts and passageways, especially in the pancreas and lungs. Respiratory failure is the most dangerous consequence of CF.
Additional assessment on Antoinette include
dehydration and menorrhagia.
- A. buffalo hump and hypertension.
- B. pitting edema and frequent colds.
- C. migraine headache and dymennorhea.
Correct Answer: B
Rationale: Cushing's syndrome results from excess adrenocortical activity. Signs include slow wound healing, buffalo hump, hirsutism, weight gain, hypertension, acne, moon face, thin arms and legs, and behavioral changes.
The nurse is caring for a client with a history of chronic kidney disease who is receiving hemodialysis. Which of the following findings would require immediate intervention?
- A. Blood pressure of 140/90 mmHg.
- B. Weight gain of 1 kg since last dialysis.
- C. Bright red blood in the dialysis tubing.
- D. Potassium level of 4.5 mEq/L.
Correct Answer: C
Rationale: Bright red blood in the dialysis tubing indicates a potential access site bleed or tubing disconnection, requiring immediate intervention to prevent blood loss. Mild hypertension (A) and weight gain (B) are common, and a normal potassium level (D) is unremarkable.