Nokea
The nurse is performing an assessment on a client with a history of pancreatitis. Which finding is most concerning?
- A. Abdominal tenderness
- B. Nausea and vomiting
- C. Fever of 101°F
- D. Grey-Turner’s sign
Correct Answer: D
Rationale: Grey-Turner’s sign (flank bruising) indicates retroperitoneal hemorrhage in pancreatitis, a life-threatening complication requiring immediate attention. Other findings are common but less severe.
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The nurse is performing discharge teaching to the parents of a seven-year-old who has been diagnosed with asthma. Which sports activity would be most appropriate for this client?
- A. Baseball
- B. Swimming
- C. Football
- D. Track
Correct Answer: B
Rationale: Swimming is ideal for asthma patients, as the warm, humid air reduces bronchospasm risk. Baseball (A), football (C), and track (D) involve outdoor or high-exertion activities that may trigger asthma.
A 26-year-old client has no children. She has had an abdominal hysterectomy. In the first 24 hours postoperatively, the nurse would be concerned if the client:
- A. Cries easily and says she is having abdominal pain
- B. Develops a temperature of 102°F
- C. Has no bowel sounds
- D. Has a urine output of 200 mL for 4 hours
Correct Answer: B
Rationale: The client may be more tearful than normal due to the stress of the surgery and its implications for her future life. She would be expected to have pain following surgery. A temperature of 102°F indicates an infectious process. This is not a normal sequence to surgery and indicates a need for further assessment. The client is expected to have no bowel sounds for 24-48 hours after surgery because of the trauma to the bowel. Normal urine output is 30 mL/hr. This represents an output of 50 mL/hr, which is greater than normal.
A client has been admitted to the labor and delivery unit in active labor. After assessing her, the RN notes that the client's fetus position is left occipital posterior. Which of the following statements best describes what this means to the labor process:
- A. Decreases the overall time of the labor process
- B. Prolongs the client's first stage of labor
- C. Decreases the time of the client's first stage of labor
- D. Prolongs the client's third stage of labor
Correct Answer: B
Rationale: The left occipital posterior position presents a larger fetal head diameter, increasing pressure on sacral nerves and prolonging the first stage of labor due to slower fetal descent.
A client delivered a stillborn male at term. An appropriate action of the nurse would be to:
- A. State, 'You have an angel in heaven.'
- B. Discourage the parents from seeing the baby.
- C. Provide an opportunity for the parents to see and hold the baby for an undetermined amount of time.
- D. Reassure the parents that they can have other children.
Correct Answer: C
Rationale: This is not a supportive statement. There are also no data to indicate the family's religious beliefs. Seeing their baby assists the parents in the grieving process. This gives them the opportunity to say 'good-bye.' Parents need time to get to know their baby. This is not a comforting statement when a baby has died. There are also no guarantees that the couple will be able to have another child.
A mother brings her 3-year-old child who is unconscious but breathing to the ER with an apparent drug overdose. The mother found an empty bottle of aspirin next to her child in the bathroom. Which nursing action is the most appropriate?
- A. Put in a nasogastric tube and lavage the child's stomach.
- B. Monitor muscular status.
- C. Teach mother poison prevention techniques.
- D. Place child on respiratory assistance.
Correct Answer: A
Rationale: The immediate treatment for drug overdose is removal of the drug from the stomach by either forced emesis or gastric lavage. The child's unconscious state prohibits forced emesis. Toxic amounts of salicylates directly affect the respiratory system, which could lead to respiratory failure. The mother's anxiety is probably so high that preventive guidance will be ineffective. Respiratory assistance is not needed if the child's respiratory function is unaltered.