Nokea
Which of the following actions should the nurse take?
- A. Place the client in a side-lying position prior to assessing the fetal heart rate.
- B. Measure the fundal height to determine the placement of the ultrasound stethoscope.
- C. Position the ultrasound stethoscope above the symphysis pubis to assess the fetal heart rate.
- D. Perform Leopold maneuvers prior to auscultating the fetal heart rate.
Correct Answer: C
Rationale: The correct answer is C: Position the ultrasound stethoscope above the symphysis pubis to assess the fetal heart rate. This is the correct action because placing the ultrasound stethoscope above the symphysis pubis allows for optimal detection of the fetal heart rate. This location is where the fetal heart sounds are best heard due to the proximity to the fetal heart. Placing the stethoscope in this location ensures accurate assessment of the fetal heart rate.
Choice A is incorrect because placing the client in a side-lying position is not necessary for assessing the fetal heart rate with an ultrasound stethoscope. Choice B is incorrect because measuring fundal height is not relevant to assessing the fetal heart rate. Choice D is incorrect because Leopold maneuvers are used to determine fetal position and presentation, not to assess the fetal heart rate.
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A nurse is performing a skin assessment on a client who has dark skin. Which of the following locations on the client's body should the nurse observe to assess for cyanosis?
- A. Sacrum
- B. Palms of the hands
- C. Shoulders
- D. Area of trauma
Correct Answer: B
Rationale: The correct answer is B: Palms of the hands. In dark-skinned individuals, cyanosis may not be as apparent in typical areas like lips or nail beds. Palms of the hands are a reliable location to assess for cyanosis as they have less melanin and blood vessels close to the surface, making cyanosis more visible. The other choices (A: Sacrum, C: Shoulders, D: Area of trauma) are not ideal locations to assess for cyanosis as they are less likely to show accurate signs due to differences in skin thickness, blood vessel distribution, and melanin content.
A quality control nurse is reviewing medication prescriptions for a group of clients. Which of the following medication prescriptions should the nurse identify as being complete?
- A. Tetracycline 200 mg PO
- B. Epoetin alfa 150 units/kg three times weekly
- C. Digoxin 0.25 mg PD dally
- D. Cimetidine PO twice daily
Correct Answer: C
Rationale: The correct answer is C: Digoxin 0.25 mg PO daily. The rationale for this choice being complete is that it includes the medication name (Digoxin), dose (0.25 mg), route of administration (PO - by mouth), and frequency (daily). This prescription is clear and specific, providing all necessary information for the nurse to accurately administer the medication.
Other choices are incorrect:
A: Missing frequency information.
B: Missing route of administration and frequency.
D: Missing dose and frequency.
Which of the following responses should the nurse make?
- A. It is always difficult caring for someone who is terminally ill.
- B. You should consider taking a sleeping pill before bed each night.
- C. I can give you information about respite care if you are interested.
- D. I am sure you're doing a great job taking care of your mother.
Correct Answer: C
Rationale: Respite care provides temporary relief for caregivers, which can improve their well-being.
A nurse is assessing a client who is postoperative following abdominal surgery and has an indwelling urinary catheter that is draining dark yellow urine at 25 mL/hr. Which of the following interventions should the nurse anticipate?
- A. Initiate continuous bladder irrigation.
- B. Administer a fluid bolus
- C. Clamp the catheter tubing for 30 min.
- D. Obtain a urine specimen for culture and sensitive
Correct Answer: B
Rationale: The correct answer is B: Administer a fluid bolus. The dark yellow urine output at 25 mL/hr indicates concentrated urine and potential dehydration. Administering a fluid bolus would help improve hydration status and increase urine output. Continuous bladder irrigation (A) is not indicated as there is no indication of bladder obstruction. Clamping the catheter tubing (C) can lead to urinary retention and should not be done without a specific reason. Obtaining a urine specimen for culture (D) is important, but addressing the dehydration issue takes priority.
Which of the following information should the nurse include?
- A. Information Technology will install a firewall to secure client information
- B. You will be asked to change your password once per year.
- C. Documentation of sensitive material is performed by the charge nurse.
- D. You will be given access to the medical records of every client in the facility.
Correct Answer: A
Rationale: Firewalls help protect sensitive client information in electronic health records.