Nokea
Which of the following findings should the nurse report to the provider? Select all that apply.
- A. Respiratory findings
- B. Oxygen saturation
- C. Central nervous system findings
- D. Gastrointestinal findings
Correct Answer: C,D
Rationale: The nurse should report central nervous system (CNS) and gastrointestinal (GI) findings to the provider because changes in these systems can indicate serious health issues. CNS findings may suggest neurological problems, while GI findings could indicate digestive issues or potential complications. Reporting these findings promptly allows the provider to assess the patient's condition thoroughly and intervene if necessary. Respiratory and oxygen saturation findings are important but may not always require immediate intervention. Other choices are not directly related to critical health concerns that need urgent attention.
You may also like to solve these questions
A nurse is assessing a client who is postpartum and has idiopathic thrombocytopenia purpura (ITP). Which of the following findings should the nurse expect?
- A. Decreased platelet count
- B. Increased erythrocyte sedimentation rate (ESR)
- C. Decreased megakaryocytes
- D. Increased WBC
Correct Answer: A
Rationale: The correct answer is A: Decreased platelet count. In ITP, there is a decrease in the number of platelets, leading to an increased risk of bleeding. Platelets are essential for blood clotting, so a decreased count can result in easy bruising, petechiae, and prolonged bleeding. The other choices are incorrect because in ITP, there is no significant increase in ESR, decrease in megakaryocytes (which are platelet precursors), or increase in WBC count. By understanding the pathophysiology of ITP and its effects on platelets, we can confidently select choice A as the expected finding in this scenario.
A nurse is providing dietary teaching to a client who has hyperemesis gravidarum. Which of the following statements by the client indicates an understanding of the teaching?
- A. "I will eat foods that taste good instead of balancing my meals."
- B. "I will avoid having a snack before I go to bed each night."
- C. "I will have a cup of hot tea with each meal."
- D. "I will eliminate products that contain dairy from my diet."
Correct Answer: D
Rationale: The correct answer is D: "I will eliminate products that contain dairy from my diet." This is correct because dairy products can exacerbate nausea and vomiting in hyperemesis gravidarum. Dairy is often harder to digest and can trigger gastrointestinal distress. Avoiding dairy can help reduce symptoms and improve tolerance to food.
Choice A is incorrect because focusing on taste over balanced nutrition is not advisable for someone with hyperemesis gravidarum. Choice B is irrelevant to the condition. Choice C is also not recommended as caffeine in tea can worsen nausea.
A nurse is assessing a client who is 3 days postpartum. Which of the following findings should the nurse report to the provider?
- A. Cool, clammy skin
- B. Moderate lochia serosa
- C. Heart rate 89/min
- D. BP 120/70 mm Hg
Correct Answer: A
Rationale: The correct answer is A: Cool, clammy skin. This finding could indicate hypovolemic shock, a serious postpartum complication. The nurse should report this to the provider immediately for further evaluation and intervention to prevent deterioration. Moderate lochia serosa (B) is expected 3 days postpartum. Heart rate of 89/min (C) and BP of 120/70 mm Hg (D) are within normal range for a postpartum client and do not require immediate reporting.
A nurse is teaching a client who is at 37 weeks of gestation and has a prescription for a nonstress test. Which of the following instructions should the nurse include?
- A. The test should take 10 to 15 minutes to complete.
- B. You will lay in a supine position throughout the test.
- C. You should not eat or drink for 2 hours before the test.
- D. You should press the handheld button when you feel your baby move.
Correct Answer: D
Rationale: Rationale: The correct answer is D because pressing the handheld button when feeling the baby move helps monitor fetal heart rate and movements during the test. This action allows healthcare providers to assess the baby's well-being. Choice A is incorrect as the test duration varies. Choice B is wrong as the client should lay on their left side, not supine, to prevent compression of the vena cava. Choice C is incorrect as eating and drinking are not restricted before the test.
A nurse is caring for a client who is at 22 weeks of gestation and is HIV positive. Which of the following actions should the nurse take?
- A. Administer penicillin G 2.4 million units IM to the client.
- B. Instruct the client to schedule an annual pelvic examination.
- C. Tell the client they will start medication for HIV immediately after delivery.
- D. Report the client’s condition to the local health department.
Correct Answer: D
Rationale: The correct answer is D: Report the client’s condition to the local health department. This is crucial to ensure proper monitoring, contact tracing, and prevention of transmission to others. Reporting the client's HIV status is mandatory for public health purposes. Administering penicillin G (choice A) is not relevant in this scenario. Instructing the client to schedule a pelvic exam (choice B) and starting HIV medication after delivery (choice C) are not immediate actions needed to address the client's HIV status.