Nokea
The nurse is using Naegel's Rule to estimate the expected date of delivery. The correct method of determining date of delivery is to:
- A. Subtract 30 days and add 3 months to the first day of the last menstrual period.
- B. Subtract 3 months and add 30 days to the last day of the last menstrual period.
- C. Subtract 3 months and add 7 days to the first day of the last menstrual period.
- D. Subtract 10 days and add 7 months to the last menstrual period.
Correct Answer: C
Rationale: Naegel's Rule calculates the expected delivery date by subtracting 3 months and adding 7 days to the first day of the last menstrual period.
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Which laboratory test conducted on the client with diabetes mellitus indicates compliance?
- A. Fasting blood glucose
- B. Two-hour post-prandial
- C. Hgb A-1C
- D. Dextrostix
Correct Answer: C
Rationale: Hgb A-1C reflects average blood glucose over 2-3 months, indicating long-term compliance. Options A, B, and D provide short-term snapshots and are less reliable for compliance.
During the physical assessment, the nurse determines the need to perform the bulge Test .
Which of the following statements, if made by the nurse, is BEST?
- A. Please lie down and extend your legs.
- B. Please bend over and touch your toes.
- C. Please hold both hands behind your back.
- D. Please bend your elbow.
Correct Answer: A
Rationale: Strategy: Think about each answer choice. (1) correct-bulge Test confirms presence of fluid in the knee; client's leg should be extended and supported on the bed (2) observing curve of spine; scoliosis will cause lateral curve in the spine (3) unrelated to knee examination (4) Test s articulation of elbow
A client is currently hospitalized with renal failure and has 3+ pitting edema of the lower extremities.
Which of the following nursing observations would indicate a therapeutic response to therapy for the edema?
- A. Serum potassium 4.0 mEq/L.
- B. Plasma glucose 140 mg/dL.
- C. Increased specific gravity of the urine.
- D. Weight loss of 5 lb over last two days.
Correct Answer: D
Rationale: Strategy: Determine how each answer choice relates to edema. (1) no relation to edema (2) no relation to edema (3) urine specific gravity may be decreased as client begins to lose some edema fluid (4) correct-edema is a result of sodium and fluid retention; weight loss should occur if therapy is effective
A client has just been admitted after sustaining a second-degree thermal injury to his right arm.
Which of the following nursing observations is MOST important to report to the doctor?
- A. Pain around the periphery of the injury.
- B. Gastric pH less than 6.0.
- C. Increased edema of the right arm.
- D. An elevated hematocrit.
Correct Answer: B
Rationale: Strategy: Determine how each assessment relates to burns. (1) expected findings in burn wound resolution (2) correct-decrease in gastric pH could indicate hypersecretion of hydrogen ions, predisposing factor to stress ulcer formation (3) expected findings in burn wound resolution (4) expected findings in burn wound resolution
The nurse is teaching a client with a new diagnosis of hypothyroidism about levothyroxine (Synthroid). Which of the following statements by the client indicates a need for further teaching?
- A. I should take this medication in the morning.
- B. I should report chest pain to my doctor.
- C. I should avoid taking this with calcium supplements.
- D. I should stop this medication if I feel better.
Correct Answer: D
Rationale: Stopping levothyroxine when feeling better is incorrect, as hypothyroidism requires lifelong replacement therapy to maintain euthyroid status. Options A, B, and C are correct: morning dosing minimizes insomnia, chest pain may indicate overdose, and calcium supplements interfere with absorption.