Nokea
A client after an electroconvulsive therapy (ECT) treatment.
The nurse should report which observation to the client's physician?
- A. Headache.
- B. Disruption in short- and long-term memory.
- C. Transient confusional state.
- D. Backache.
Correct Answer: D
Rationale: Strategy: You are looking for something unexpected. (1) expected effect (2) expected effect (3) expected effect (4) correct-client undergoing ECT needs to be instructed about what s/he could experience during and after ECT; expected effects include headache, disrupted memory (short- and long-term), and general confused state; backache is not a usual effect; thorough description of the pain in relation to severity, duration, location, and what makes pain better needs to be assessed and reported to the physician
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Which of the following meal choices is suitable for a 6-month-old infant?
- A. Egg white, formula, and orange juice
- B. Apple juice, carrots, and whole milk
- C. Rice cereal, formula, and apple juice
- D. Melba toast, egg yolk, and whole milk
Correct Answer: C
Rationale: Rice cereal, formula, and apple juice are appropriate for a 6-month-old, as they are easily digestible and safe. Egg whites, whole milk, and orange juice are not recommended before 1 year due to allergy and digestive risks.
The nurse is receiving reports about four pregnant women in active labor who have been admitted to the labor and delivery unit. Which of the following women should the nurse see FIRST?
- A. A 27-year-old nullipara at 38-weeks gestation, has a cervical dilatation of $2 \mathrm{~cm}$, fetus in transverse lie with baseline FHT of $155 \mathrm{bpm}$.
- B. A 32-year-old multipara at term, cervical dilatation of $8 \mathrm{~cm}$, fetus in a vertex presentation with the presenting part at +2 station.
- C. A 22-year-old nullipara at term, cervical dilatation of $10 \mathrm{~cm}, 100 \%$ effaced, fetus presenting as left occiput posterior with short-term variability of the FHT at 3-5 beats.
- D. A 34-year-old multipara at 37-weeks gestation, has intact amniotic membranes, cervical dilatation of $3 \mathrm{~cm}$, and fetus in a frank breech presentation with the presenting part at 0 station.
Correct Answer: B
Rationale: The multipara at 8 cm dilatation is in advanced labor and likely to deliver soon, making her the priority. Options A, C, and D are less urgent: transverse lie needs monitoring, nullipara at 10 cm has a longer second stage, and breech at 3 cm is early.
The nurse is caring for a client who is receiving a blood transfusion. Which of the following findings would be of GREATest concern to the nurse?
- A. Temperature of 100.4°F (38°C).
- B. Heart rate of 90 bpm.
- C. Respiratory rate of 18 breaths/min.
- D. Blood pressure of 120/80 mmHg.
Correct Answer: A
Rationale: A temperature of 100.4°F during a blood transfusion suggests a transfusion reaction, such as febrile non-hemolytic reaction, requiring immediate cessation of the transfusion. Options B, C, and D are normal: heart rate 90 bpm, respiratory rate 18 breaths/min, and blood pressure 120/80 mmHg do not indicate complications.
The nurse is caring for a client who is postoperative day 1 after a coronary artery bypass graft (CABG). Which of the following findings should the nurse report immediately?
- A. Heart rate of 90 bpm.
- B. Temperature of 100.8°F (38.2°C).
- C. Chest tube drainage of 50 mL/hour.
- D. Blood pressure of 130/80 mmHg.
Correct Answer: B
Rationale: A temperature of 100.8°F suggests infection, a serious post-CABG complication. Options A, C, and D are normal or expected.
The nurse is caring for a client with a history of tuberculosis.
- A. Which precaution is most appropriate for a client with active tuberculosis?
- B. Standard precautions.
- C. Droplet precautions.
- D. Contact precautions.
- E. Airborne precautions.
Correct Answer: D
Rationale: Airborne precautions are required for active tuberculosis to prevent transmission via respiratory droplets. Standard, droplet, and contact precautions are insufficient.