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Which fetal heart monitor pattern can indicate cord compression?
- A. variable decelerations
- B. early decelerations
- C. bradycardia
- D. tachycardia
Correct Answer: A
Rationale: The correct answer is A: variable decelerations. Variable decelerations are abrupt decreases in fetal heart rate that vary in depth, duration, and timing, which can indicate cord compression. The variability in these decelerations suggests that the umbilical cord is being compressed intermittently.
Early decelerations (B) are usually caused by head compression during contractions and mirror the contractions, not indicating cord compression. Bradycardia (C) is a slow heart rate, which can be caused by various factors but is not specific to cord compression. Tachycardia (D) is a fast heart rate, which can also be caused by various factors but is not typically associated with cord compression.
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What should be the nurse's first action when caring for a client with a traumatic amputation?
- A. Apply pressure and elevate the limb
- B. Stop the bleeding and control shock
- C. Place the client in a Trendelenburg position
- D. Place the client in a sitting position
Correct Answer: A
Rationale: The correct first action is A: Apply pressure and elevate the limb. This is because applying pressure helps control bleeding and elevating the limb reduces blood flow to the area, minimizing further blood loss. This immediate intervention is crucial in managing the traumatic amputation and preventing complications.
Summary of why other choices are incorrect:
B: Stopping bleeding and controlling shock can be important but not the first action.
C: Placing the client in a Trendelenburg position (feet elevated higher than the head) is contraindicated in cases of traumatic amputation as it can increase bleeding.
D: Placing the client in a sitting position is not appropriate as it can worsen bleeding and lead to further complications.
Which is included only in a comprehensive assessment?
- A. Circulatory assessment
- B. Assessment of the airway
- C. Complete health history
- D. Disability assessment
Correct Answer: C
Rationale: The correct answer is C: Complete health history. In a comprehensive assessment, obtaining a complete health history is essential to gather information about the patient's past and present health conditions, including medical history, family history, social history, and current symptoms. This information helps the healthcare provider understand the patient's overall health status, identify risk factors, and develop an appropriate treatment plan. Assessing the circulatory system (A) and airway (B) are important components of a physical assessment, but they alone do not constitute a comprehensive assessment. Disability assessment (D) focuses on the functional limitations caused by a disability and is not always included in a comprehensive health assessment.
A patient is at the clinic to have her blood pressure checkeShe has been coming to the clinic weekly since her medications were changed 2 months ago. The nurse should:
- A. collect a follow-up database and then check the patient's blood pressure.
- B. ask the patient to read her health record and indicate any changes since her last visit.
- C. check only the blood pressure because the patient's complete health history was documented 2 months ago.
- D. obtain a complete health history before checking the blood pressure because much of the patient's information may have changed.
Correct Answer: A
Rationale: Rationale:
1. Collecting a follow-up database ensures up-to-date information.
2. It allows for monitoring of medication effectiveness and any new symptoms.
3. Checking the blood pressure is essential but needs current context.
4. Asking the patient to read her record may not provide all necessary updates.
5. The complete health history is crucial but obtaining it first may delay urgent blood pressure check.
Which intervention should be performed when assessing a client with an arteriovenous fistula (AVF) for hemodialysis?
- A. Check the patency of the fistula
- B. Monitor for bleeding
- C. Administer IV fluids
- D. Apply an airtight dressing
Correct Answer: C
Rationale: Correct Answer: C - Administer IV fluids
Rationale:
1. Assess patient's fluid status and hydration level.
2. IV fluids help maintain adequate hydration during hemodialysis.
3. Prevents hypotension and ensures stable blood pressure during the procedure.
4. Improves overall hemodialysis efficiency and patient safety.
Summary:
A: Checking patency is important, but not the primary intervention for hemodialysis.
B: Monitoring for bleeding is crucial but not specific to AVF assessment.
D: Applying an airtight dressing is not necessary for AVF assessment.
Which quadrant of the abdomen is tender in suspected appendicitis?
- A. upper right
- B. upper left
- C. lower right
- D. lower left
Correct Answer: C
Rationale: The correct quadrant for tenderness in suspected appendicitis is the lower right quadrant (Choice C). This is because the appendix is located in the lower right abdomen. Appendicitis typically presents with pain starting around the navel and then localizing to the lower right quadrant. The other choices, upper right (Choice A), upper left (Choice B), and lower left (Choice D) are incorrect as they do not correspond to the typical location of the appendix. Upper right quadrant is where the liver and gallbladder are situated, upper left quadrant contains the stomach and spleen, and lower left quadrant has the colon and left ovary/testis.