Nokea
The nurse is reviewing the client's medical record. Select 4 findings that indicate a potential prenatal complication.
- A. Urine protein
- B. Fetal activity
- C. Blood pressure
- D. Urine ketones
- E. Respiratory rate
- F. Report of headache
- G. Gravida/parity
Correct Answer: A, B, C, F
Rationale: The correct answer includes findings that are indicative of potential prenatal complications.
A: Urine protein can indicate preeclampsia, a serious condition in pregnancy.
B: Fetal activity changes may suggest fetal distress or growth restriction.
C: Blood pressure changes can indicate hypertension or preeclampsia.
F: Headache can be a symptom of preeclampsia or other serious conditions.
Choices D, E, and G are not typically associated with prenatal complications. D: Urine ketones may indicate dehydration but not necessarily a prenatal complication. E: Respiratory rate is not directly related to prenatal complications. G: Gravida/parity information is important for obstetric history but not directly indicative of current prenatal complications.
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A nurse enters a client's room and sees a small fire in the client's bathroom. Identify the sequence of steps the nurse should take.
- A. Transport the client to another area of the nursing unit.
- B. Activate the facility's fire alarm system
- C. Close all nearby windows and doors
- D. Use the unit's fire extinguisher to attempt to put out the fire
Correct Answer: B, A, C, D
Rationale: The correct sequence of steps for the nurse to take in case of a small fire in the client's bathroom is as follows:
1. B: Activate the facility's fire alarm system - This is the first step to alert everyone in the facility and ensure a prompt response from the fire department.
2. A: Transport the client to another area of the nursing unit - Ensures the client's safety away from the fire hazard.
3. C: Close all nearby windows and doors - Helps contain the fire and prevent it from spreading further.
4. D: Use the unit's fire extinguisher to attempt to put out the fire - Only after ensuring the client's safety and containing the fire should the nurse attempt to extinguish it.
Other choices are incorrect because:
- A: Transporting the client should only be done after activating the fire alarm system to ensure a timely response.
- C: Closing windows and doors is important but should be done after alerting others about the fire
Drag words from the choices below to fill in each blank in the following sentence. The client is at greatest risk for developing-----and-----
- A. Placental Abruption
- B. Hypoglycemia
- C. Heart failure
- D. Cervical insufficiency
- E. Seizures
Correct Answer: C,E
Rationale: The correct answer is C, Heart failure, and E, Seizures. The client is at greatest risk for developing heart failure and seizures due to complications during pregnancy. Heart failure can occur due to the increased stress on the heart from pregnancy, especially in individuals with pre-existing heart conditions. Seizures can arise from conditions like eclampsia, which is a severe form of preeclampsia characterized by high blood pressure and organ damage. Placental abruption (A) is a separation of the placenta from the uterus, not directly related to heart failure or seizures. Hypoglycemia (B) is low blood sugar levels, which may occur but is not the greatest risk in this scenario. Cervical insufficiency (D) is the inability of the cervix to stay closed during pregnancy, which is not directly linked to heart failure or seizures.
For each potential assessment finding, click to specify if the assessment finding is consistent with mastitis or endometritis. Each finding may support more than 1 disease process.
- A. Foul-smelling lochia
- B. Painful, tender breast
- C. Temperature
- D. Chills
Correct Answer: B: Mastitis; A, C, D: Both
Rationale: The correct answer is B: Painful, tender breast - consistent with mastitis. Mastitis is an infection of the breast tissue, causing pain and tenderness. A: Foul-smelling lochia can be seen in both mastitis and endometritis. C: Temperature can be elevated in both conditions due to infection. D: Chills can also be present in both mastitis and endometritis as a response to infection. The other choices are left blank as they do not specifically align with either mastitis or endometritis in terms of assessment findings.
A nurse is discussing discharge plans with an older adult client who lives alone and has left-sided weakness following a stroke. Which of the following information is the priority for the nurse to discuss?
- A. Reviewing information about support groups for individuals who have had a stroke
- B. Obtaining an alert system to get help in case of a fall
- C. Providing information about available transportation resources
- D. Choosing an agency to provide home physical therapy
Correct Answer: B
Rationale: The correct answer is B: Obtaining an alert system to get help in case of a fall. This is the priority because the client's left-sided weakness puts them at risk for falls, which can have serious consequences. Having an alert system ensures they can get immediate help if a fall occurs, potentially preventing injuries or complications. Reviewing support groups (A) can be beneficial but is not as urgent. Providing transportation resources (C) and choosing a home physical therapy agency (D) are important but do not address the immediate safety concern of potential falls.
A nurse is providing teaching about home safety to the adult child of an older adult client who is postoperative following hip replacement surgery. Which of the following instructions should the nurse include?
- A. Encourage the client to avoid wearing shoes at home.
- B. Place a throw rug over electrical cords
- C. Mark the edges of the doorway to the house with tape.
- D. Ensure that area rugs have rubber backs.
Correct Answer: D
Rationale: The correct answer is D: Ensure that area rugs have rubber backs. This instruction helps prevent slipping and falling, which is crucial for a postoperative hip replacement patient. Rubber-backed rugs provide stability and reduce the risk of accidents. Option A is incorrect as wearing shoes at home can increase the risk of falls. Option B is incorrect as placing a throw rug over electrical cords can lead to tripping hazards. Option C is incorrect as marking doorways with tape does not address home safety concerns for a postoperative patient.