Nokea
When assessing a laboring client, the nurse finds a prolapsed cord. The nurse should:
- A. Attempt to replace the cord
- B. Place the client on her left side
- C. Elevate the client's hips
- D. Cover the cord with a dry, sterile gauze
Correct Answer: C
Rationale: Elevating the hips relieves pressure on the prolapsed cord, maintaining fetal oxygenation.
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The registered nurse is conducting an in-service for colleagues on the subject of peptic ulcers. The nurse would be correct in identifying which of the following as a causative factor?
- A. N. gonorrhea
- B. H. influenza
- C. H. pylori
- D. E. coli
Correct Answer: C
Rationale: H. pylori is a primary causative factor in peptic ulcers, contributing to mucosal damage and ulcer formation.
The nurse in an ambulatory care clinic is admitting a 27-year-old client with severe systemic lupus erythematosus (SLE). In assessing the client's health history, the nurse knows to question which of the following statements?
- A. I avoid being outside on sunny days.
- B. The medications I take make me bloated.
- C. My work schedule is down to four hours a day.
- D. I get an eye exam annually.
Correct Answer: D
Rationale: Annual eye exams may not be sufficient for SLE, as the condition and its treatments can cause frequent eye complications, requiring more regular monitoring.
A nurse has received report on the day's clients. In planning morning rounds, which client is the priority to see?
- A. a new admission with a UTI and fever
- B. a client who is NPO for surgery later in the morning
- C. a client complaining of nausea after eating breakfast
- D. a client recently complaining of shortness of breath
Correct Answer: D
Rationale: Shortness of breath indicates a potential respiratory or cardiac issue, making this client the priority for immediate assessment.
The nurse is caring for an organ donor client with a severe head injury from an MVA. Which of the following is most important when caring for the organ donor client?
- A. Maintenance of the BP at 90 mmHg or greater
- B. Maintenance of a normal temperature
- C. Keeping the hematocrit at less than 28%
- D. Ensuring a urinary output of at least 300 mL/hr
Correct Answer: A
Rationale: Maintaining BP at 90 mmHg or greater ensures organ perfusion, critical for organ viability in a donor. Normal temperature and adequate urine output are important, but BP is the priority. Low hematocrit is not a goal.
A client admitted with gastroenteritis and a potassium level of 2.9 mEq/dL has been placed on telemetry. Which ECG finding would the nurse expect to find due to the client's potassium results?
- A. A depressed ST segment
- B. An elevated T wave
- C. An absent P wave
- D. A flattened QRS
Correct Answer: A
Rationale: Hypokalemia (2.9 mEq/dL) can cause a depressed ST segment, flattened T waves, and prominent U waves on ECG due to altered cardiac repolarization.