Nokea
What is the expected date of delivery for your pregnant client when her last menstrual period was on 10/20/2016?
- A. 7/7/2017
- B. 8/7/2017
- C. 6/7/2017
- D. 8/1/2017
Correct Answer: A
Rationale: Using Naegele's rule, add 1 year and 7 days to the first day of the last menstrual period (10/20/2016), then subtract 3 months: 10/20/2016 + 1 year = 10/20/2017, + 7 days = 10/27/2017, - 3 months = 7/27/2017. Adjusting for a standard 40-week gestation, the expected delivery date is approximately 7/7/2017.
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A client has soft wrist restraints to prevent her from pulling out her nasogastric tube. Which of the following nursing interventions should be implemented while the restraints are on the client?
- A. Instruct the client not to move while the restraints are in place
- B. Remove the restraints every 4 hours to provide skin care
- C. Secure the restraints to side rails of the bed
- D. Check on the client every 30 minutes while the restraints are on
Correct Answer: D
Rationale: Checking the client every 30 minutes ensures safety, circulation, and skin integrity while restraints are in use. Restraints should be removed every 2 hours for care, not 4, and securing to side rails is unsafe.
A client is receiving a blood transfusion when he begins to complain of difficulty breathing. The nurse notes an elevated blood pressure and a cough. Based on these signs, the nurse should prepare to manage which of the following complications?
- A. Anaphylactic reaction.
- B. Circulatory overload.
- C. Sepsis.
- D. Acute hemolytic reaction.
Correct Answer: B
Rationale: Difficulty breathing, elevated blood pressure, and cough suggest circulatory overload, a transfusion complication due to fluid volume excess.
The best way to objectively evaluate the effectiveness of an individual staff member's time management skills in a longitudinal manner is to:
- A. Observe the staff member during an entire shift of duty to determine whether or not the nurse has accurately and appropriately established priorities.
- B. Observe the staff member during an entire shift of duty to determine whether or not the nurse has accurately and appropriately completed priority tasks.
- C. Ask the staff member how they feel like they have been able to employ their time management skills for the last six months.
- D. Collect outcome data over time and then aggregate and analyze this data to determine whether or not the staff member has completed reasonable assignments in the allotted time before the end of their shift of duty.
Correct Answer: D
Rationale: To objectively evaluate time management skills over time, collecting, aggregating, and analyzing outcome data provides a longitudinal perspective on whether the staff member consistently completes assignments within the allotted time. This method is more objective than single-shift observations (A, B) or self-reports .
The nurse is teaching a client with a new ileostomy about dietary modifications. Which food should be avoided?
- A. Rice.
- B. Corn.
- C. Bananas.
- D. Yogurt.
Correct Answer: B
Rationale: Corn is high in fiber and hard to digest, which can cause blockages in a new ileostomy.
You routinely use the PQRST method to assess pain. The PQRST method consists of:
- A. Pain level, the quality of the pain, the region or area of the pain, the severity of the pain, and the pain triggers
- B. Precipitating factors, the quality of the pain, relief factors, the severity of the pain, and the pain triggers
- C. Pain level, the quantitative numerical pain score, the region or area of the pain, the severity of the pain, and the pain triggers
- D. Precipitating factors, the quality of the pain, the region or area of the pain, the severity of the pain, and the pain triggers
Correct Answer: D
Rationale: The PQRST method assesses pain through Precipitating factors, Quality, Region, Severity, and Timing (triggers).