Nokea
When planning care for a woman who is admitted in labor, it is most important for the nurse to obtain which of the following information about the client?
- A. Age of the client and due date
- B. Frequency and duration of contractions
- C. Whether the membranes have ruptured
- D. Who will be assisting the woman during labor
Correct Answer: B
Rationale: Contraction frequency and duration indicate labor progress and urgency, guiding immediate care. Age, due date, membrane status, and support persons are secondary.
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The nurse is caring for a child receiving chest physiotherapy (CPT). Which of the following actions by the nurse would be appropriate?
- A. Schedule the therapy thirty minutes after meals
- B. Teach the child not to cough during the treatment
- C. Continue the percussion to the rib cage area
- D. Place the child in a prone position for the therapy
Correct Answer: C
Rationale: Continue the percussion to the rib cage area. Percussion should target the rib cage to mobilize secretions effectively.
The nurse is caring for a client with COPD who becomes dyspneic. The nurse should
- A. instruct the client to breathe into a paper bag
- B. place the client in a high Fowler's position
- C. assist the client with pursed lip breathing
- D. administer oxygen at 6L/minute via nasal cannula
Correct Answer: C
Rationale: Use pursed-lip breathing during periods of dyspnea to control rate and depth of respiration and improve respiratory muscle coordination.
Which of these clients would be appropriate to assign to a practical nurse (PN)?
- A. A trauma victim with multiple lacerations and requires complex dressings
- B. An elderly client with cystitis and an indwelling urethral catheter
- C. A confused client whose family complains about the nursing care 2 days after surgery
- D. A client admitted for possible transient ischemic attack with unstable neurological signs
Correct Answer: B
Rationale: This is a stable client, with predictable outcome and care and minimal risk for complications.
The nurse prepares a client for discharge following a vasectomy. The client asks, 'When can I have sexual intercourse with my wife without using a condom?' What is the best response by the nurse?
- A. Discontinue alternative birth control after at least 5 ejaculations.
- B. There is no need to use alternative birth control following today's procedure.
- C. Use alternative birth control for 6 months following today's procedure.
- D. Use alternative birth control until your physician confirms the absence of sperm in a semen analysis.
Correct Answer: D
Rationale: A vasectomy requires confirmation of azoospermia via semen analysis, typically after 6-12 weeks or 15-20 ejaculations, to ensure sterility. Alternative birth control (C) is needed until this confirmation. Immediate unprotected intercourse (A) risks pregnancy, and 6 months (B) is unnecessarily long.
The nurse is caring for a client with immune thrombocytopenic purpura. Which client statements indicate a need for further teaching? Select all that apply.
- A. I use a soft-bristle toothbrush and mild mouth rinse.
- B. I enjoy walking and wear nonskid footwear for safety.
- C. I use a safety razor and gentle shaving cream.
- D. I sometimes get constipated, so I have been taking docusate.
- E. I when I have a headache, I take over-the-counter ibuprofen.
Correct Answer: C,E
Rationale: ITP increases bleeding risk. Using a safety razor (C) risks cuts, and ibuprofen (E) inhibits platelets, both requiring further teaching. Soft toothbrush (A), safe walking (B), and docusate (D) are appropriate.