Nokea
Which of the following assessments would be a priority when documenting the nursing history of a two-year-old child?
- A. The child's rituals and routines at home.
- B. The child's understanding of hospitalization.
- C. The child's ability to be separated from the parents.
- D. The parent's methods for dealing with the child's temper tantrums.
Correct Answer: A
Rationale: during a crisis such as hospitalization, children are able to establish a sense of security through consistency of the rituals and routines from home
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The nurse assesses a prolonged deceleration of the fetal heart rate while the client is receiving oxytocin IV to stimulate labor. The priority nursing intervention would be to
- A. discontinue the infusion.
- B. turn client to the left side.
- C. change the fluids to LR.
- D. increase the IV flow rate.
Correct Answer: A
Rationale: will decrease contractions and thus possibly remove uterine pressure to the fetus, which is possibly cause of deceleration
A client is admitted with a suspected pulmonary embolism. Which of the following diagnostic tests should the nurse anticipate being ordered?
- A. Chest X-ray.
- B. D-dimer blood test.
- C. Echocardiogram.
- D. Arterial blood gas analysis.
Correct Answer: B
Rationale: D-dimer is a specific test to detect blood clots, highly sensitive for pulmonary embolism
The nurse is caring for a client who is postoperative day 1 following a total knee replacement. Which of the following findings should the nurse report to the physician immediately?
- A. Pain at the surgical site rated 6/10.
- B. Swelling and warmth at the incision site.
- C. Urine output of 150 mL over 8 hours.
- D. Serosanguineous drainage on the dressing.
Correct Answer: B
Rationale: swelling and warmth may indicate infection or a deep vein thrombosis, which requires immediate attention
The nurse is caring for a client with a history of type 2 diabetes who is receiving sitagliptin (Januvia) 100 mg PO daily. Which of the following client statements would be of GREATest concern to the nurse?
- A. I have a headache sometimes.
- B. I feel tired in the afternoon.
- C. I have pain in my upper abdomen.
- D. I take my medication with breakfast.
Correct Answer: C
Rationale: Upper abdominal pain may indicate pancreatitis, a rare but serious side effect of sitagliptin, requiring immediate evaluation. Options A, B, and D are less concerning: headaches and fatigue are nonspecific, and taking with breakfast is acceptable.
Which of the following strategies would be MOST therapeutic as the nurse tries to analyze a bulimic client's eating habits and the circumstances that precipitate the client's eating problems?
- A. Observe family communication patterns at a 'monitored mealtime.'
- B. Distract the client at mealtime.
- C. Assign the client a food/feelings/thoughts/actions journal.
- D. Assign the client to write a 'lifeline' in relation to eating behaviors.
Correct Answer: C
Rationale: implementation, nurse is trying to analyze and understand what triggers the client's binging and purging activities, so therapeutic nursing intervention of assigning a thought/feelings/actions (T/F/A) journal relating to client's eating behaviors will be most helpful to the nurse and therapeutic to the client; after this information is gained and reviewed, collaboration by the nurse and client on other strategies such as delay and distraction techniques, stress reduction, and developing a 'lifeline' in relation to eating behaviors will further benefit the client