Nokea
The nurse is performing Leopold's maneuvers on a woman who is in her eighth month of pregnancy. The nurse is palpating the uterus as shown by the following maneuvers is the nurse performing?
- A. First maneuver.
- B. Second maneuver.
- C. Third maneuver.
- D. Fourth maneuver.
Correct Answer: C
Rationale: The third Leopold's maneuver involves palpating the lower uterus to determine the presenting part, typically performed in the eighth month to assess fetal position.
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During you musculoskeletal assessment of the client, you determine that the client has muscular strength against gravity but not against resistance. You would document this assessment as:
- A. 1 on the scale of 1 to 3
- B. 2 on the scale of 1 to 5
- C. 3 on the scale of 0 to 5
- D. 4 on the scale of 0 to 5
Correct Answer: C
Rationale: Muscular strength against gravity but not resistance is graded as 3 on the 0-5 scale, indicating fair strength.
The nurse is caring for a client with a history of atrial fibrillation who is prescribed vernakalant (Brinavess). The nurse should monitor the client for which of the following side effects?
- A. Hypertension.
- B. Bradycardia.
- C. Liver toxicity.
- D. Weight gain.
Correct Answer: B
Rationale: Vernakalant can cause bradycardia, requiring close monitoring of heart rate.
Your client is in the special care area of your hospital with multiple trauma and severe bodily burns. This 45 year old male client has an advance directive that states that the client wants all life saving measures including cardiopulmonary resuscitation and advance cardiac life support, including mechanical ventilation. As you are caring for the client, the client has a complete cardiac and respiratory arrest. This client has little of no chance for survival and they are facing imminent death according to your professional judgement, knowledge of pathophysiology and your critical thinking. You believe that all life saving measures for this client would be futile. What is the first thing that you, as the nurse, should do?
- A. Call the doctor and advise them that the client's physical status has significantly changed and that they have just had a cardiopulmonary arrest.
- B. Begin cardiopulmonary resuscitation other emergency life saving measures.
- C. Notify the family of the client's condition and ask them what they should be done for the client.
- D. Insure that the client is without any distressing signs and symptoms at the end of life.
Correct Answer: B
Rationale: The client's advance directive clearly states a desire for all life-saving measures, including CPR and advanced cardiac life support. Despite the nurse's professional judgment about futility, the nurse is legally and ethically obligated to follow the advance directive and initiate CPR immediately in the event of a cardiac and respiratory arrest. Notifying the doctor or family or ensuring comfort are secondary actions after initiating life-saving measures as per the client's documented wishes.
A client receives morphine for postoperative pain. Which of the following assessments should the nurse include in the client's plan of care?
- A. Take apical heart rate after each dose of morphine.
- B. Assess urinary output every 8 hours.
- C. Assess mental status every shift.
- D. Check for pedal edema every 4 hours.
Correct Answer: C
Rationale: Morphine can cause sedation and altered mental status, requiring regular assessment to monitor for adverse effects.
A normal, healthy infant is brought to the clinic for the first immunization against polio. The nurse should administer this vaccine by what route?
- A. Oral route.
- B. I.M. route.
- C. Subcutaneous route.
- D. Intradermal route.
Correct Answer: A
Rationale: The polio vaccine for infants is administered orally (OPV) in many regions, though inactivated polio vaccine (IPV) is given intramuscularly in some settings. Based on the options, oral is correct.