Nokea
A nurse receives report about assigned clients at the start of the shift. Which of the following clients should the nurse plan to see first?
- A. A client who experienced a cesarean birth 4 hr ago and reports pain
- B. A client who has preeclampsia with a BP of 138/90 mm Hg
- C. A client who experienced a vaginal birth 24 hr ago and reports no bleeding
- D. A client who is scheduled for discharge following a laparoscopic tubal ligation Which of the following findings indicates that it is safe for the nurse to continue the infusion? .
Correct Answer: A
Rationale: The client who experienced a cesarean birth 4 hours ago and is reporting pain should be seen first by the nurse. Pain assessment and management are crucial following a cesarean birth to ensure the client's comfort and well-being. Uncontrolled pain can lead to complications and affect the client's recovery process. Addressing the client's pain promptly is a priority to promote their comfort and facilitate their recovery.
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What is the nurse's role when preparing a mother for epidural anesthesia?
- A. Monitor the mother's contractions
- B. Ensure the mother has an empty bladder
- C. Ensure the mother is in a supine position
- D. Administer a test dose of the epidural medication
Correct Answer: C
Rationale: Ensuring the bladder is empty helps prevent complications during epidural anesthesia.
A nurse is conducting an orientation program for a group of newly hired nurses. As part of the program, the nurse is reviewing the issue of informed consent. The nurse determines that the teaching was effective when the group identifies which situation as a violation of informed consent?
- A. Performing a procedure on a 15-year-old without parental consent
- B. Serving as a witness to the signature process on an operative permit
- C. Asking whether the client understands what she is signing following receiving education
- D. Getting verbal consent over the phone for an emergency procedure from the spouse of a unconscious woman
Correct Answer: A
Rationale: In most states, only clients over the age of 18 can legally provide consent for health care. Serving as a witness to the signature process, asking whether the client understands what she is signing, and getting verbal consent over the phone for emergency procedures are all key to informed consent and are not violations.
What findings would make the nurse suspicious of anorexia in a client?
- A. Aversion to exercise and food allergies.
- B. Significant weight loss and amenorrhea.
- C. Respiratory distress and thick oral mucus.
- D. Cardiac arrhythmias and anasarca.
Correct Answer: B
Rationale: Weight loss and amenorrhea are hallmark signs of anorexia.
Which interpretation of the data from Table 3-1 is correct?
- A. When one considers those who "read/heard" about the vaccine, there is no significant difference between the percentage of students who received the immunization and those who did not receive the immunization.
- B. The likelihood of students who receive the vaccine when they learned about it from the "health history form" was about 1.6 times that of the "health history form" students who did not receive the vaccine.
- C. 44.4% of those who were not vaccinated received their information from "Letters."
- D. The largest percentage of students who received the vaccine learned about it from the "University Health Service (UHS) providers."
Correct Answer: D
Rationale: According to the table, the largest percentage of vaccinated students learned about the vaccine from UHS providers.
If a newborn is born with acrocyanosis (blue/pale extremities and a pink body), they should be assigned which Apgar score for appearance?
- B. 1
- C. 2
- D. 3
Correct Answer: B
Rationale: Acrocyanosis typically receives a score of 1 for appearance.