Nokea
The nurse observes a woman in the first stage of labor and encourages her to push before the cervix is fully dilated. The nurse's action could primarily lead to
- A. Call the health care provider
- B. Encourage deep breathing
- C. Elevate the foot of the bed
- D. Turn her to her left side
Correct Answer: D
Rationale: The weight of the uterus can put pressure on the vena cava and aorta when a pregnant woman is flat on her back causing supine hypotension. Turning the woman to the side reduces this pressure and relieves postural hypotension.
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The nurse is assessing a client with a history of asthma who presents with wheezing and shortness of breath. The nurse should prioritize which of the following actions?
- A. Administer a bronchodilator as ordered.
- B. Place the client in a supine position.
- C. Obtain a chest X-ray.
- D. Teach the client deep breathing exercises.
Correct Answer: A
Rationale: Wheezing and shortness of breath in asthma indicate bronchoconstriction, and administering a bronchodilator (e.g., albuterol) as ordered is the priority to relieve airway obstruction. Supine positioning (B) worsens breathing, X-rays (C) are diagnostic, and deep breathing (D) is secondary.
While assessing a pre-op client, the nurse learns that the client is allergic to shellfish. How might this data affect the client's surgical experience?
- A. The anesthesiologist might need to alter the type of anesthesia used.
- B. The physician might need to alter the type of skin preparation used.
- C. The physician might need to alter the type of antibiotics ordered post-operatively.
- D. The physician might need to monitor the client's thyroid levels post-operatively.
Correct Answer: B
Rationale: Shellfish allergy indicates potential iodine sensitivity, which may require altering the skin preparation (e.g., avoiding iodine-based solutions like Betadine).
The nurse is caring for an 11-year-old patient being treated for a fractured right femur with balanced suspension traction with a Thomas splint and Pearson attachment. The nurse notes that the patient's left leg is externally rotated. The nurse should
- A. place a trochanter roll on the outer aspect of the thigh.
- B. perform resistive range of motion of the left leg.
- C. adduct and internally rotate the left leg.
- D. instruct the patient to maintain the left leg in a neutral position.
Correct Answer: A
Rationale: A trochanter roll placed on the outer aspect of the thigh holds the hip in a neutral position and prevents external rotation, maintaining proper leg alignment. Resistive exercises or active movement (choices B and C) do not address alignment, and instructing the patient (choice D) is ineffective without physical support.
When teaching how to use nitroglycerin, the nurse tells the client to place 1 tablet under the tongue when pain occurs and to repeat the dose in 5 minutes if pain persists. The nurse should also tell the client to
- A. place 2 tablets under the tongue when intense pain occurs.
- B. swallow 1 tablet and place under the tongue when pain is intense.
- C. place 1 tablet under the tongue 3 minutes before activity and repeat the dose in 5 minutes if pain occurs.
- D. place 1 tablet under the tongue when pain occurs and use an additional tablet after the attack to prevent recurrence.
Correct Answer: D
Rationale: Anginal pain, which can be anticipated during certain activities, may be prevented by dilating the coronary arteries immediately before engaging in activity, and an additional tablet post-attack can prevent recurrence.
Which of the following is a correctly stated nursing diagnosis for a client with abruptio placentae?
- A. Infection related to obstetrical trauma.
- B. Potential for fetal injury related to abruptio placentae.
- C. Potential alteration in tissue perfusion related to depletion of fibrinogen.
- D. Fluid volume deficit related to bleeding.
Correct Answer: D
Rationale: Abruptio placentae causes hemorrhage due to premature placental separation, leading to fluid volume deficit, a major nursing concern. Infection (A) is unrelated, and choices B and C are incorrectly phrased nursing diagnoses.