Nokea
The nurse performing a prenatal assessment on a client in the first trimester of pregnancy discovers that the client frequently consumes beverages containing alcohol. Why should the nurse initiate interventions immediately to assist the client in avoiding alcohol consumption?
- A. To reduce the potential for fetal growth restriction in utero
- B. To promote the normal psychosocial adaptation of the mother to pregnancy
- C. To minimize the potential for placental abruptions during the intrapartum period
- D. To reduce the risk of teratogenic effects to embryo's developing fetal organs and tissue
Correct Answer: D
Rationale: Alcohol consumption during the first trimester poses a significant risk for teratogenic effects, as this is a critical period for organogenesis in the developing embryo. Exposure to alcohol can lead to fetal alcohol syndrome or other congenital anomalies, making immediate intervention essential to protect fetal development. While fetal growth restriction, psychosocial adaptation, and placental abruption are concerns, they are less directly associated with early pregnancy alcohol exposure compared to teratogenic effects.
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A client diagnosed with both a wound infection and osteomyelitis is to receive hyperbaric oxygen therapy. During the therapy, which priority intervention should the nurse implement?
- A. Maintaining an intravenous access
- B. Ensuring that oxygen is being delivered
- C. Administering sedation to prevent claustrophobia
- D. Providing emotional support to the client's family
Correct Answer: B
Rationale: Hyperbaric oxygen therapy is a process by which oxygen is administered at greater than atmospheric pressure. When oxygen is inhaled under pressure, the level of tissue oxygen is greatly increased. The high levels of oxygen promote the action of phagocytes and promote healing of the wound. Because the client is placed in a closed chamber, the administration of oxygen is of primary importance. Although options 1, 3, and 4 may be appropriate interventions, option 2 is the priority.
The nurse is reviewing the record of a client with a disorder involving the inner ear. Which finding should the nurse most likely note as an assessment finding in this client?
- A. Tinnitus
- B. Burning in the ear
- C. Itching in the affected ear
- D. Severe pain in the affected ear
Correct Answer: A
Rationale: Tinnitus is the most common complaint of clients with ear disorders, especially disorders involving the inner ear. Manifestations of tinnitus can range from mild ringing in the ear that can go unnoticed during the day to a loud roaring in the ear that can interfere with the client's thinking process and attention span. The assessment findings noted in options 2, 3, and 4 are not specifically noted in the client with an inner ear disorder.
The nurse has administered approximately half of a high-cleansing enema when the client reports pain and cramping. Which nursing action is appropriate?
- A. Reassuring the client that those sensations will subside
- B. Discontinuing the enema and notifying the primary health care provider
- C. Raising the enema bag so that the solution can be introduced quickly
- D. Clamping the tubing for 30 seconds and restarting the flow at a slower rate
Correct Answer: D
Rationale: The enema fluid should be administered slowly. If the client complains of pain or cramping, the flow is stopped for 30 seconds and restarted at a slower rate. Slow enema administration and stopping the flow temporarily, if necessary, will decrease the likelihood of intestinal spasm and premature ejection of the solution. The client's report of pain and cramping should not be ignored. The higher the solution container is held above the rectum, the faster the flow and the greater the force in the rectum. There is no need to discontinue the enema and notify the primary health care provider at this time.
A client is admitted after attempting suicide by ingesting a prescribed antipsychotic medication. What is the most important piece of information the nurse should obtain initially?
- A. Where and when the medication was ingested
- B. The name and amount of ingested medication
- C. If the client continues to have suicidal ideations
- D. If there is a history of previous suicidal attempts
Correct Answer: B
Rationale: In an emergency, lifesaving facts are obtained first. The name of and the amount of medication ingested is of utmost importance in treating this potentially life-threatening situation. The remaining data can be assessed once the client's physical condition is stabilized.
The nurse is reviewing the records of recently admitted clients to the postpartum unit. The nurse determines that which clients would have an increased risk for developing a puerperal infection? Select all that apply.
- A. A client with a history of previous infections
- B. A client who has given birth to a set of twins
- C. A client who had numerous vaginal examinations
- D. A client who has experienced three previous miscarriages
- E. A client who underwent a vaginal delivery of the newborn
- F. A client who experienced prolonged rupture of the membranes
Correct Answer: A,C,F
Rationale: Risk factors associated with puerperal infection include a history of previous infections, excessive number of vaginal examinations, cesarean births, prolonged rupture of the membranes, prolonged labor, trauma, and retained placental fragments. A vaginal delivery, a history of miscarriages, and the delivery of twins are not considered as risk factors for developing a puerperal infection.