Nokea
A 25-year-old woman after a vaginal delivery.
Which of the following is the FIRST nursing action that should be implemented for a 25-year-old woman after a vaginal delivery?
- A. Check the patient's lochial flow.
- B. Palpate the patient's fundus.
- C. Monitor the patient's pain.
- D. Assess the patient's level of consciousness.
Correct Answer: A
Rationale: Strategy: 'FIRST' indicates that this is a priority question. Remember the ABCs. (1) correct-complication of hemorrhage assessed by observing lochial flow (2) done to assist its natural clamping-down action, assessed as firm or boggy (3) must meet physical needs first (4) not first action, hemorrhage most important complication
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A 15-month-old child has just been diagnosed with sickle cell anemia. The mother is pregnant and asks if the child she is carrying will also have sickle cell anemia. She says that neither she nor her husband has sickle cell anemia. The nurse's reply should be based on which understanding?
- A. There is a 50% chance that each child they have will have sickle cell anemia.
- B. The chance of having another child with sickle cell anemia is 1 in 4.
- C. Parents do not usually have two children in a row with sickle cell anemia.
- D. If the child is a boy, there is a 50% chance that he will have sickle cell anemia.
Correct Answer: B
Rationale: Sickle cell anemia is autosomal recessive; if both parents are carriers (trait), there's a 25% (1 in 4) chance per child of inheriting the disease, independent of gender or prior children.
A client has been taking perphenazine (Trilafon) by mouth for two days and now displays the following: head turned to the side, neck arched at an angle, stiffness and muscle spasms in neck.
- A. Which PRN medication should the nurse expect to give for a client with extrapyramidal side effects from perphenazine?
- B. Promazine (Sparine).
- C. Biperiden (Akineton).
- D. Thiothixene (Navane).
- E. Haloperidol (Haldol).
Correct Answer: B
Rationale: Biperiden, an antiparkinsonian agent, counteracts extrapyramidal side effects (e.g., dystonia, stiffness) caused by antipsychotics like perphenazine. Promazine, thiothixene, and haloperidol are antipsychotics that could worsen these side effects.
A nurse performing actions that would be considered negligence.
Which of the following actions, if performed by the nurse, would be considered negligence?
- A. Obtaining a Guthrie Blood Test on a four-day-old infant.
- B. Massaging lotion on the abdomen of a three-year-old diagnosed with Wilm's tumor.
- C. Instructing a five-year-old asthmatic to blow on a pinwheel.
- D. Playing kickball with a 10-year-old with juvenile arthritis (JA).
Correct Answer: B
Rationale: Strategy: 'Would be considered negligence' indicates an incorrect action. (1) obtain after ingestion of protein, no later than 7 days after delivery (2) correct-manipulation of mass may cause dissemination of cancer cells (3) this exercise extends expiratory time and increases expiratory pressure (4) excellent moving and stretching exercise
The nurse is caring for an adult who is enrolled in a study involving an experimental drug. The client says to the nurse, 'I don't think I can stand the vomiting anymore. I think it is due to the drug I am taking. If only I could get out of this study I signed up for. That was a really stupid thing I did when I signed up for the study.' What information must the nurse include when responding to the client?
- A. If the client signed the proper forms, the client is committed to the study.
- B. Persons who have signed up for a study may opt out of the study at any time.
- C. The person should discuss his/her concerns with the researchers.
- D. Inform the client that there are drugs that can control nausea.
Correct Answer: B
Rationale: Participants can withdraw from research studies at any time, per ethical research guidelines, ensuring autonomy and safety.
A 2 year-old child has just been diagnosed with cystic fibrosis. The child's father asks the nurse 'What is our major concern now, and what will we have to deal with in the future?' Which of the following is the best response?
- A. There is a probability of life-long complications.
- B. Cystic fibrosis results in nutritional concerns that can be dealt with.
- C. Thin, tenacious secretions from the lungs are a constant struggle in cystic fibrosis.
- D. You will work with a team of experts and also have access to a support group that the family can attend.
Correct Answer: C
Rationale: Thin, tenacious secretions from the lungs are a constant struggle in cystic fibrosis. Respiratory issues are the primary concern due to chronic lung complications.