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A nurse is caring for a client who is in active labor.
The nurse should notify the provider for which of the following findings?
- A. Baseline fetal heart rate 115/min
- B. Three uterine contractions within 10 minutes
- C. Prolonged decelerations
- D. Moderate variability in the fetal heart rate
Correct Answer: C
Rationale: The correct answer is C: Prolonged decelerations. This finding indicates potential fetal distress, requiring immediate provider notification to assess and intervene. Baseline fetal heart rate (A) within normal range is reassuring. Three uterine contractions (B) could be normal. Moderate variability (D) is a positive sign of fetal well-being. The focus should be on abnormal findings like prolonged decelerations (C) that may indicate compromised fetal oxygenation.
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A nurse is teaching dietary guidelines to a client who has celiac disease.
Which of the following food choices is appropriate for this client?
- A. Canned barley soup
- B. Potato pancakes.
- C. Wheat crackers
- D. White flour tortillas
Correct Answer: B
Rationale: The correct answer is B: Potato pancakes. This choice is appropriate as it is likely to be well-tolerated by the client. Potatoes are a good source of carbohydrates and can provide energy. Additionally, potato pancakes are easy to digest and can be a good option for someone with digestive issues. On the other hand, A, C, and D contain grains that may be harder to digest for some individuals, especially if they have digestive concerns. Canned barley soup (A) may also contain added preservatives and sodium, which may not be ideal for the client's condition. Wheat crackers (C) can be high in fiber and may be difficult to digest. White flour tortillas (D) are made from refined grains and may not provide the necessary nutrients for the client.
A charge nurse is teaching a newly licensed nurse about medication Administration. Which of the following information should the charge nurse include?
- A. Avoid preparing medications for more than two clients at one time.
- B. Inform clients about the action of the medication Prior to administration.
- C. Read medication labels at least two times prior to administration.
- D. Complete an incident report if a client vomits after taking a medication.
Correct Answer: C
Rationale: The correct answer is C: Read medication labels at least two times prior to administration. This is crucial to ensure accurate medication administration and prevent medication errors. Reading labels twice helps in verifying the right medication, dose, route, and time. It is a standard safety practice in medication administration. Option A is incorrect as there is no specific rule about preparing medications for multiple clients. Option B is important but not as critical as double-checking the medication labels. Option D is important in certain situations but not directly related to medication administration technique.
A nurse is assessing a client who has a possible right pneumothorax.
Which of the following findings should the nurse expect?
- A. Reduce right sided breath sounds
- B. Inter coastal retractions
- C. High pitched strider
- D. Paradoxical chest movement
Correct Answer: A
Rationale: The correct answer is A: Reduced right-sided breath sounds. This finding suggests a potential pneumothorax on the right side, where air leaks into the pleural space causing lung collapse and decreased breath sounds. Intercostal retractions (B) indicate increased work of breathing, likely due to respiratory distress but not specific to a pneumothorax. High-pitched stridor (C) is a sign of upper airway obstruction, not typically seen with pneumothorax. Paradoxical chest movement (D) is seen in flail chest, not characteristic of pneumothorax.
A nurse in an outpatient clinic is caring for a client.
Assessment
0840:
Client is calm and cooperative. Skin warm and dry. No rash noted. Lung sounds clear. Abdomen
soft to palpation with fundal height at 20 cm. Fetal heart rate 150/min. Bowel sounds active in all
four quadrants. No edema to lower extremities. Client denies visual changes or severe headaches.
Weight gain of 1.8 kg (4 lb) since last visit. Small amount of mucoid discharge noted on perineal
pad
Laboratory Results
0900:
Urine dipstick:
pH 6.0 mg/d (4.6 to 8 mg/dL)
Specific Gravity 1.022 (1.010 to 1.025)
Leukocyte esterase negative (Negative)
Nitrite negative (Negative)
Protein trace negative (Negative)
Glucose negative (Negative)
Ketones none (None)
Bilirubin none (None)
Blood none (None)
Nurses' Notes
0830:
Client reports to clinic for monthly prenatal visit. Client is at 20 weeks of gestation. Since last
visit, client reports concerns about the occurrence of intermittent mild backaches, increased
heartburn, generalized itching, and vaginal discharge.
Vital Signs
0830:
BP 124/68 mm Hg
Heart rate 80/min
Temperature 37° C (98.6° F)
Respiratory rate 16/min
Weight 67.1 kg (148 lb)
Which of the following statements should the nurse include in the client's teaching?
- A. Take hot showers to help relieve itching
- B. Wear flat or low-heeled shoes
- C. You can douche twice weekly
- D. Wear loose-fitting clothing
- E. Try using an abdominal support belt
- F. You should avoid fried foods
- G. Eat two large meals a day
Correct Answer: B,D,F
Rationale: Wearing flat shoes, wearing loose-fitting clothes, and avoiding fried foods are beneficial practices during pregnancy.
Provider Prescriptions
1030:
Obtain x-rays of right arm, wrist, and elbow.
Drag words from the choices below to fill in each blank.Nurse should anticipate a prescription for--------and-------
- A. skin traction
- B. surgical consultation
- C. pain medication
- D. limb immobilization
- E. antibiotics
- F. bed rest
Correct Answer: C,D
Rationale: Pain medication and limb immobilization are standard for managing fractures, reducing discomfort and promoting healing.