Nokea
The nurse is talking with the parent of a 1-day-old female client who has a small amount of blood-tinged, mucoid vaginal drainage. Which of the following statements would be most appropriate for the nurse to make?
- A. Laboratory tests will need to be performed to determine your baby's hormone levels.
- B. The health care provider will prescribe a medication to stop the bleeding.
- C. We will continue to monitor the amount, color, and consistency of the drainage.
- D. What visitors have been present since your baby was born?
Correct Answer: C
Rationale: Blood-tinged vaginal drainage in a newborn is often due to maternal hormone exposure and typically resolves. Monitoring is appropriate.
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The nurse is caring for a client who has been in alcohol detoxification for one week. The client has slurred speech and is bumping into doorframes and walking unsteadily. What is the most appropriate initial action by the nurse?
- A. Assess for Wernicke-Korsakoff syndrome
- B. Ask for an order for blood alcohol level
- C. Request a neurology consult
- D. Administer a PRN dose of diazepam (Valium)
Correct Answer: A
Rationale: Slurred speech and unsteady gait post-detox may indicate Wernicke-Korsakoff syndrome, a thiamine deficiency complication, requiring urgent assessment.
The nurse is caring for a client who is having a thoracentesis. Following the procedure, the nurse monitors for complications. The initial post-procedure monitoring plan should include what? Select all that apply.
- A. Level of alertness
- B. Lung sounds
- C. Oxygen saturation
- D. Respiratory pattern
- E. Temperature
- F. Urine output
Correct Answer: A,B,C,D
Rationale: Monitoring alertness, lung sounds, oxygen saturation, and respiratory pattern detects complications like pneumothorax or respiratory distress.
The nurse is talking with a client whose spouse recently attempted suicide. The client states, 'If I had not intervened, my spouse would have died. I cannot believe this is happening.' Which of the following responses would be most appropriate for the nurse to make?
- A. Do not focus on the negative. You should try to focus on helping your spouse get better.
- B. I imagine that this is overwhelming. Tell me more about how you are feeling right now.
- C. Do you have any relatives or close friends who can help support you through this?
- D. Has your spouse been experiencing worsening depression recently?
Correct Answer: B
Rationale: Acknowledging the client's feelings and encouraging expression provides emotional support.
The nurse is observing the movements of a client receiving Thorazine (chlorpromazine). The client continually paces and rocks back and forth when sitting. The nurse recognizes that the client is experiencing:
- A. Oculogyric crisis
- B. Akathisia
- C. Dystonia
- D. Bradykinesia
Correct Answer: B
Rationale: Akathisia is characterized by restlessness, pacing, and rocking, which matches the client's symptoms. Answer A involves fixed upward gaze, Answer C involves muscle spasms, and Answer D involves slowed movements, all of which are incorrect.
The nurse is caring for a client diagnosed with active pulmonary tuberculosis. Which elements of transmission-based precautions are required for the nurse when providing routine care? Select all that apply.
- A. Gown
- B. Goggles or face shield
- C. Hand hygiene
- D. N95 particulate respirator
- E. Surgical mask
Correct Answer: C,D
Rationale: Active pulmonary tuberculosis requires airborne precautions, including hand hygiene and an N95 respirator. A surgical mask is insufficient.