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The nurse is to administer a tuberculin skin test. At what angle should the needle be inserted?
- A. A 10-degree angle
- B. A 30-degree angle
- C. A 60-degree angle
- D. A 90-degree angle
Correct Answer: A
Rationale: A 10-degree angle ensures intradermal injection for a tuberculin skin test, creating a wheal for accurate reading.
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While collecting data from pregnant clients in the obstetric clinic, the nurse should alert the health care provider to see which client first?
- A. First-trimester client who reports frequent nausea and vomiting
- B. Second-trimester client with dysuria and urinary frequency
- C. Second-trimester client with obesity who reports decrease in fetal movement
- D. Third-trimester client with right upper quadrant pain and nausea
Correct Answer: C
Rationale: Decreased fetal movement in the second trimester suggests potential fetal distress, requiring urgent evaluation. Nausea, UTI symptoms, and third-trimester pain are concerning but less immediately critical.
A nurse assigns a task to unlicensed assistive personnel. They state, 'We can’t do that.' Which is the best initial response for the nurse to make?
- A. Ask the unlicensed assistive personnel (UAP) the reason for the response
- B. Do the task, but discuss the UAP’s response with the manager
- C. Ignore the UAP’s initial response and repeat the assigned request
- D. Remind the UAP of the importance of teamwork
Correct Answer: A
Rationale: Asking the reason clarifies whether the refusal is due to scope, training, or other issues, promoting collaboration. Performing the task, ignoring, or lecturing avoids addressing the root cause.
The nurse is performing a developmental assessment on a 12-month-old client. Which of the following findings are expected at this age? Select all that apply.
- A. Birth weight has tripled
- B. Cruises along furniture
- C. Kicks a ball
- D. Searches for hidden objects
- E. Speaks in two word phrases
Correct Answer: A,B,D
Rationale: By 12 months, infants typically triple birth weight, cruise along furniture, and search for hidden objects (object permanence). Kicking a ball and two-word phrases are expected at 18-24 months.
A woman in a residence facility is having difficulty sleeping at night. Which action by the nurse is most appropriate initially?
- A. Ask the physician for a sleeping medication
- B. Offer the woman a back rub and warm milk
- C. Suggest to the woman that she take a walk around the unit
- D. Offer the woman a cup of hot tea
Correct Answer: B
Rationale: A back rub and warm milk promote relaxation non-pharmacologically, addressing insomnia safely. Medication, walking, or tea (caffeine) are less appropriate.
The nurse is reviewing the chart of a client who gave birth 4 hours ago. Which factor increases the client's risk for postpartum hemorrhage?
- A. Labor and birth without pain medication
- B. Labor length of 8 hours
- C. Newborn weight of 9 lb 2 oz (4140 g)
- D. Third stage of labor lasting 20 minutes
Correct Answer: C
Rationale: A large newborn (macrosomia, >4000 g) increases the risk of uterine atony, a major cause of postpartum hemorrhage. Labor without pain medication, an 8-hour labor, and a 20-minute third stage are not significant risk factors.