Nokea
The PN is caring for a laboring client whose last sterile vaginal examination revealed the cervix was 3 cm dilated, 50% effaced, and the presenting part was at 0 station. An hour later, the client tells the PN that she wants to go to the bathroom. Which action is most important for the PN to implement?
- A. Review the fetal heart rate and contraction pattern
- B. Check the perineum for an increase in bloody show
- C. Request a nurse to check the client's cervical dilation
- D. Palpate the client's bladder for distention
Correct Answer: C
Rationale: The sudden urge to use the bathroom may indicate that labor is progressing quickly. Checking the cervical dilation will help determine if the client is in the transition phase of labor and if it is appropriate to allow her to get up. Reviewing the fetal heart rate and contraction pattern (Choice A) is important but not the most immediate action in this scenario. Checking the perineum for an increase in bloody show (Choice B) is relevant but not as crucial as assessing cervical dilation. Palpating the client's bladder for distention (Choice D) is not the priority when the client wants to go to the bathroom during labor.
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A client post-lobectomy is placed on mechanical ventilation. The nurse notices the client is fighting the ventilator. What should the nurse do first?
- A. Increase the sedation as prescribed.
- B. Manually ventilate the client using an ambu bag.
- C. Check the ventilator settings and alarms.
- D. Suction the client's airway.
Correct Answer: C
Rationale: The correct first action for the nurse to take when a client is fighting the ventilator is to check the ventilator settings and alarms. This step is crucial to ensure that the ventilator is functioning correctly and providing the necessary support to the client. Increasing sedation (Choice A) should only be considered after confirming that the ventilator settings are appropriate. While manually ventilating the client (Choice B) may be required in some cases, it is not the initial action to take. Suctioning the client's airway (Choice D) is not the priority in this situation, where the primary concern is addressing the client's struggle with the ventilator.
In obtaining an orthostatic vital sign measurement, what action should the nurse take first?
- A. Count the client's radial pulse
- B. Apply a blood pressure cuff
- C. Instruct the client to lie supine
- D. Assist the client to stand upright
Correct Answer: C
Rationale: The correct first action when obtaining an orthostatic vital sign measurement is to instruct the client to lie supine. This allows for establishing a baseline measurement of vital signs before any positional changes. Counting the client's radial pulse (Choice A) is a step that follows after the initial supine position to assess changes in pulse rate. Applying a blood pressure cuff (Choice B) and assisting the client to stand upright (Choice D) are actions that come later in the process after the baseline measurements are obtained in the supine position.
When caring for a child with sickle cell disease, the PN expects that the child will most likely describe which symptom when experiencing a sickle cell crisis?
- A. Decreased hemoglobin
- B. Joint pain
- C. Fatigue
- D. Infection
Correct Answer: B
Rationale: During a sickle cell crisis, a child with sickle cell disease is most likely to describe joint pain. Sickle cell disease leads to the blockage of blood flow by sickled red blood cells, causing ischemia and pain, often felt in the joints and other body parts. Fatigue (choice C) is a nonspecific symptom that can occur in various conditions but is not a characteristic symptom of a sickle cell crisis. While decreased hemoglobin (choice A) can be observed in sickle cell disease, it is not a symptom typically described by a child during a sickle cell crisis. Infection (choice D) can trigger a sickle cell crisis but is not the symptom most likely to be described by the child during the crisis.
The PN observes a UAP preparing to exit a client's room. The UAP's hands appear visibly soiled as the UAP uses a hand rub for 19 seconds to cleanse the hands. Which action should the PN take?
- A. Confirm that the UAP completed hand hygiene correctly
- B. Instruct the UAP to wash the hands for one minute
- C. Ask the UAP why the hands were so obviously soiled
- D. Advise the UAP to use the hand rub for 30 seconds
Correct Answer: D
Rationale: When hands are visibly soiled, they should be washed with soap and water for at least 20 seconds. However, when using hand rub, it should be applied for at least 30 seconds to be effective. In this scenario, the UAP's hands were visibly soiled, indicating the need for thorough cleaning. Advising the UAP to use the hand rub for 30 seconds is essential to ensure proper hand hygiene and reduce the risk of spreading infection. Choices A, B, and C are incorrect because confirming completion of hand hygiene, instructing to wash for one minute, or asking why the hands were soiled do not address the immediate need for proper hand hygiene in the given situation.
Which assessment finding would most likely indicate a complication of enteral tube feeding?
- A. Abdominal distension
- B. Weight gain
- C. Decreased bowel sounds
- D. Diarrhea
Correct Answer: A
Rationale: Abdominal distension in a patient receiving enteral tube feeding may indicate a complication such as intolerance to feeding, delayed gastric emptying, or obstruction. Abdominal distension is a common sign of gastrointestinal issues related to enteral tube feeding. Weight gain is typically an expected outcome if the patient is receiving adequate nutrition. Decreased bowel sounds may indicate decreased motility but are not specific to enteral tube feeding complications. Diarrhea can occur due to various reasons, including infections, medications, or dietary changes, but it is not the most likely indication of a complication in enteral tube feeding.