Nokea
The nurse is reinforcing teaching with a client who is starting to use a cervical cap for contraception. Which client statement would require follow-up?
- A. I should apply spermicide to the cervical cap before inserting it.
- B. I can insert the cervical cap several hours before I have sexual intercourse.
- C. I should leave the cervical cap in place for at least 24 hours after intercourse.
Correct Answer: C
Rationale: Leaving the cervical cap in for at least 24 hours increases infection risk; it should remain for 6-8 hours post-intercourse. Applying spermicide and inserting hours before intercourse are correct practices for effective use.
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The nurse is caring for a 45-year-old client with atrial fibrillation who has been receiving diltiazem. Which of the following findings would indicate that the medication has been effective?
- A. Blood pressure of 126/78 mm Hg
- B. Client does not have chest pain
- C. Client has not experienced any signs of stroke
- D. Ventricular rate decreased from 158/min to 88/min
Correct Answer: D
Rationale: Diltiazem is used in atrial fibrillation to control ventricular rate. A decrease from 158/min to 88/min indicates effective rate control. Blood pressure, chest pain, and stroke prevention are not primary indicators of diltiazem's efficacy in this context.
A nurse is documenting notes in the client's electronic record after making rounds on assigned clients. Which entry is an appropriate documentation?
- A. Client appears to be sleeping. Eyes closed
- B. Client reports, 'I'm in pain.' Medication provided
- C. Inspiratory wheezes heard in bilateral lower lung fields
- D. Voided x1
Correct Answer: C
Rationale: Inspiratory wheezes in bilateral lower lung fields is a specific, objective finding that accurately describes the client's condition. The other entries are vague, lack detail, or are subjective without supporting data.
A health care provider is screaming at the nurse in the hallway. 'Why didn't you get that surgery scheduled sooner?' What is the best response by the nurse?
- A. I am so sorry; I will get this fixed and schedule the surgery immediately
- B. I am uncomfortable with your tone, please excuse me while I locate my supervisor
- C. I delegated this task to the unlicensed assistive personnel: please follow up with them.
- D. I think you are overreacting, you should have specified the day and time
Correct Answer: B
Rationale: Responding calmly and redirecting to a supervisor de-escalates the situation professionally while addressing the inappropriate tone. Accusing the provider of overreacting is confrontational and unprofessional.
The nurse enters the room of an adult who is having a grand mal seizure. Which initial action is appropriate?
- A. Put a padded tongue blade in the client's mouth.
- B. Restrain the client.
- C. Turn the client's head to the side.
- D. Call the physician immediately.
Correct Answer: C
Rationale: Turning the head to the side during a seizure prevents airway obstruction by saliva or vomit, prioritizing safety, unlike tongue blades (risk injury), restraints, or immediate physician calls.
A client begins a regimen of chemotherapy. Her platelet counts falls to 98,000. Which action is least likely to increase the risk of hemorrhage?
- A. Test all excreta for occult blood.
- B. Use a soft toothbrush or foam cleaner for oral hygiene.
- C. Implement reverse isolation.
- D. Avoid IM injections.
Correct Answer: C
Rationale: Reverse isolation protects against infection but does not affect hemorrhage risk. The other actions directly reduce bleeding risk by detecting or preventing trauma to tissues. Physiological Adaptation