Nokea
The nurse notes variable decelerations on the fetal monitor strip. The most appropriate initial action would be to:
- A. Notify her.Concurrent doctor
- B. Increase the rate of IV fluid
- C. Reposition the client
- D. Readjust the monitor
Correct Answer: C
Rationale: Repositioning the client can relieve umbilical cord compression, the common cause of variable decelerations.
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Which instruction should be given to the client who is fitted for a behind-the-ear hearing aid?
- A. Remove the mold and clean every week.
- B. Store the hearing aid in a warm place.
- C. Clean the lint from the hearing aid with a toothpick.
- D. Change the batteries weekly.
Correct Answer: A
Rationale: Regular cleaning of the hearing aid mold prevents wax buildup and ensures proper function.
The physician has ordered a paracentesis for a client with severe abdominal ascites. Before the procedure, the nurse should:
- A. Provide the client with a urinal
- B. Prep the area by shaving the abdomen
- C. Encourage the client to drink extra fluids
- D. Request an ultrasound of the abdomen
Correct Answer: A
Rationale: Providing a urinal allows the client to empty their bladder, reducing the risk of bladder puncture during paracentesis.
When using restraints for an agitated/aggressive patient, which of the following statements should NOT influence the nurse’s actions during this intervention?
- A. The restraints/seclusion policies set forth by the institution.
- B. The patient’s competence.
- C. The patient’s voluntary/involuntary status.
- D. The patient’s nursing care plan.
Correct Answer: C
Rationale: the need for restraints is based on patient’s behavioral status and condition, not the patient’s voluntary/involuntary status
The nurse is caring for a client with B-Thalassemia major. Which therapy is used to treat Thalassemia?
- A. IV fluids
- B. Frequent blood transfusions
- C. Oxygen therapy
- D. Iron therapy
Correct Answer: B
Rationale: Frequent transfusions manage severe anemia in B-Thalassemia major.
The nurse is caring for a client with suspected AIDS dementia complex. The first sign of dementia in the client with AIDS is:
- A. Changes in gait
- B. Loss of concentration
- C. Problems with speech
- D. Seizures
Correct Answer: B
Rationale: Loss of concentration is an early cognitive change in AIDS dementia complex.