Nokea
Which of the following infractions can result in the revocation of the nurse's license?
- A. Failure to render care during a natural disaster
- B. Suspected negligence
- C. A felony conviction
- D. Failure to pay license renewal fees
Correct Answer: C
Rationale: A felony conviction can lead to license revocation due to its impact on professional integrity. Natural disaster response, negligence, or unpaid fees may have other consequences but are less likely to cause revocation.
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The nurse is monitoring a client who is in active labor with a cervical dilation of 6 cm. Which finding requires intervention by the nurse?
- A. Contraction duration of 95 seconds
- B. Contraction frequency of every 3 minutes
- C. Contraction intensity of 45 mm Hg
- D. Uterine resting tone of 10 mm Hg
Correct Answer: A
Rationale: Contraction duration of 95 seconds (A) is too long and may reduce fetal oxygenation, requiring intervention. Frequency (B), intensity (C), and resting tone (D) are within normal limits.
An adult is scheduled for a total laryngectomy. When preparing the client for surgery, it is essential for the nurse to take which of the following actions?
- A. Teach the client esophageal speech
- B. Teach the client how to lip read
- C. Assess the client's ability to read and write
- D. Determine the client's usual means of dealing with a sore throat
Correct Answer: C
Rationale: A laryngectomy removes the voice box, requiring alternative communication; assessing literacy ensures post-op communication via writing, critical for care planning.
A child on the playground is experiencing an anaphylactic reaction. The school nurse arrives with an EpiPen. The weather is cold and the child is wearing several layers of clothing. How should the nurse proceed with the EpiPen?
- A. Inject into the upper arm where the sleeve can be pulled up
- B. Inject into the most accessible vein
- C. Inject through the clothing into thigh and hold in place for 10 seconds
- D. Take the child inside, remove excess clothing, and inject into the thigh
Correct Answer: C
Rationale: Injecting through clothing into the thigh (C) ensures rapid administration during anaphylaxis. Arm injection (A) is incorrect, IV injection (B) is not for EpiPens, and delaying to remove clothing (D) is dangerous.
A diabetic multigravida is scheduled for an amniocentesis at 32 weeks gestation to determine the L/S ratio and phosphatidyl glycerol level. The L/S ratio is 1:1 and the presence of phosphatidyl glycerol is noted. The nurse's assessment of this data is:
- A. The infant is at low risk for congenital anomalies.
- B. The infant is at high risk for intrauterine growth retardation.
- C. The infant is at high risk for respiratory distress syndrome.
- D. The infant is at high risk for birth trauma.
Correct Answer: C
Rationale: An L/S ratio of 1:1 and presence of phosphatidyl glycerol suggest immature lungs, indicating a high risk for respiratory distress syndrome, so C is correct. Answers A, B, and D are not directly related to these findings.
The nurse is reinforcing teaching about hypoglycemia with a group of clients who have type 1 diabetes mellitus. Which of the following should the nurse include as signs or symptoms of hypoglycemia? Select all that apply.
- A. Diaphoresis
- B. Flushing
- C. Pallor
- D. Polyuria
- E. Trembling
Correct Answer: A, C, E
Rationale: Diaphoresis (A), pallor (C), and trembling (E) are signs of hypoglycemia due to sympathetic activation. Flushing (B) and polyuria (D) are not typical.