Nokea
The nurse is reinforcing education to a group of clients who are pregnant or planning pregnancy. Which of the following client statements about alcohol use in pregnancy indicate a need for further education? Select all that apply.
- A. As long as I don't binge drink, an occasional glass of wine is fine.
- B. I drank alcohol heavily before realizing I was pregnant, so there is no benefit to quitting now.
- C. If I drink alcohol, my baby may have withdrawal after birth but no permanent damage.
- D. It is important to stop drinking while I am trying to conceive.
- E. Third-trimester alcohol use is less harmful because the baby is fully developed.
Correct Answer: A,B,C,E
Rationale: No amount of alcohol is safe during pregnancy, as it can cause fetal alcohol spectrum disorders. Quitting at any point reduces harm. Alcohol can cause permanent damage, not just withdrawal. Third-trimester exposure still risks brain development. Stopping preconception is correct.
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The nurse caring for multiple clients on a medical-surgical unit should delegate which action to the nursing assistant?
- A. Assist client, post hip fracture repair, to the bathroom
- B. Check the appearance of client's wound
- C. Discontinue nasogastric tube if client tolerates oral liquids
- D. Offer orange juice to client if bedside glucose reading is <70 mg/dL (3.9 mmol/L)
Correct Answer: A
Rationale: Assisting with mobility, such as to the bathroom, is within the nursing assistant's scope. Wound assessment, tube discontinuation, and treating hypoglycemia require nursing judgment and are outside their scope.
The student nurse completes a clinical rotation in the emergency department. The instructor knows the student is able to prioritize care appropriately when the student visits which client first?
- A. 9 year-old crying with pain and swelling of the left ankle after a popping sound while playing soccer
- B. 29-year-old with neck swelling and increased pain 2 days after thyroidectomy
- C. 43-year-old with blood glucose of 423 mg/dL (23.5 mmol/L), dehydration, and trace ketones in urine
- D. 72-year-old who is incontinent with acute altered mental status and is yelling at staff
Correct Answer: B
Rationale: Neck swelling and pain post-thyroidectomy suggest possible hematoma or airway compromise, a life-threatening emergency requiring immediate assessment. Other conditions, while serious, are less immediately critical.
The nurse is reinforcing education about lifestyle modifications for a client newly diagnosed with Meniere disease. Which statement by the client indicates a need for further teaching?
- A. I need to enroll in a smoking cessation program.
- B. I need to restrict the amount of potassium in my diet.
- C. I will lie down and avoid walking unassisted during acute attacks.
- D. I will limit the amount of caffeine and alcohol that I consume.
Correct Answer: B
Rationale: Restricting potassium isn't indicated for Ménière's disease; a low-sodium diet is typically recommended to reduce fluid retention. Smoking cessation, lying down during attacks, and limiting caffeine/alcohol are appropriate.
The nurse has delegated care of a client who is very hard of hearing to an unlicensed person. Which of the following would be the least helpful information to give to the unlicensed person to better facilitate communications with the client?
- A. Reduce background noise.
- B. Adjust the hearing aid.
- C. Anticipate what the client may say and finish the statement for the client.
- D. Face the client when speaking to the client.
Correct Answer: C
Rationale: Anticipating and finishing statements risks miscommunication and frustration, least helpful for effective communication with a hearing-impaired client.
A client is admitted to the hospital with a diagnosis of deep vein thrombosis. During the initial assessment, the client complains of sudden shortness of breath. The SaO2 is 87. The priority nursing assessment at this time is
- A. bowel sounds
- B. heart rate
- C. peripheral pulses
- D. lung sounds
Correct Answer: D
Rationale: Lung sounds are critical assessments at this point. The nurse should be alert to crackles or a pleural friction rub, highly suggestive of a pulmonary embolism.