Nokea
The nurse is reinforcing teaching with a client who is having a 1-hour glucose tolerance test. Which statement by the client indicates a need for further teaching?
- A. I will have to fast for 4 hours before the test.
- B. The test involves drinking a 50-g glucose solution.
- C. I should not eat anything for 1 hour after drinking the glucose solution.
- D. A 3-hour glucose tolerance test is needed if the result of this test is elevated.
Correct Answer: A
Rationale: Fasting for 4 hours is incorrect; a 1-hour glucose tolerance test typically requires fasting for 8 hours. The other statements are correct: no eating for 1 hour after the glucose solution and a 3-hour test if results are elevated.
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Social support systems include all of the following except:
- A. call-in help lines.
- B. emotional assistance provided by others.
- C. community support groups.
- D. use of coping skills and verbalization for anger management.
Correct Answer: D
Rationale: Coping skills and verbalization are personal strategies, not social support systems, which involve external resources like help lines, emotional assistance, or groups. Psychosocial Integrity
A hospitalized child suddenly has a seizure while his family is visiting. The nurse notes whole body rigidity followed by general jerking movements. The child vomits immediately after the seizure. A priority nursing diagnosis for the child is
- A. High risk for infection related to vomiting
- B. Altered family processes related to chronic illness
- C. Fluid volume deficit related to vomiting
- D. Risk for aspiration related to loss of consciousness
Correct Answer: D
Rationale: The tonic-clonic seizure appears suddenly and often leads to brief loss of consciousness. The greatest risk for the child is from airway blockage, as might follow aspiration.
A client experiences post partum hemorrhage eight hours after the birth of twins. Following administration of IV fluids and 500 ml of whole blood, her hemoglobin and hematocrit are within normal limits. She asks the nurse whether she should continue to breast feed the infants. Which of the following is based on sound rationale?
- A. Nursing will help contract the uterus and reduce your risk of bleeding.
- B. Breastfeeding twins will take too much energy after the hemorrhage.
- C. The blood transfusion may increase the risks to you and the babies.
- D. Lactation should be delayed until the 'real milk' is secreted.
Correct Answer: A
Rationale: Stimulation of the breast during nursing releases oxytocin, which contracts the uterus, reducing the risk of further bleeding.
The greatest time savers when planning client care include all of the following except:
- A. reacting to the crisis of the moment.
- B. setting goals.
- C. planning.
- D. specifying priorities.
Correct Answer: A
Rationale: Reacting to crises is reactive and disrupts efficient care planning. Setting goals, planning, and prioritizing save time by organizing care proactively. Coordinated Care
The nurse is assisting with procedural moderate sedation (conscious sedation) at a client's bedside. The unlicensed assistive personnel (UAP) comes to the door and indicates that the client in the next room needs the nurse right now. How should the nurse respond?
- A. Ask the UAP to go back and ask the client what the current needs are
- B. Ask the UAP to stay and take over while the nurse goes to check on the client in the next room
- C. Tell the UAP to inform the client in the next room that the nurse will be there shortly
- D. Tell the UAP to tell the charge nurse about the needs of the client in the next room
Correct Answer: D
Rationale: During moderate sedation, the nurse must remain with the client to monitor vital signs and response. Directing the UAP to inform the charge nurse ensures the other client's needs are addressed without compromising the sedated client's safety. UAP cannot monitor sedation or take over.