Nokea
Which of the following positions is best for a client with preeclampsia who is in labor?
- A. Left Sims
- B. High Fowler's
- C. Trendelenburg
- D. Supine
Correct Answer: A
Rationale: The left Sims position promotes placental perfusion and reduces pressure on the vena cava in preeclampsia, improving maternal and fetal outcomes. Other positions are less optimal.
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The nurse is caring for an 80-year-old client with Parkinson’s disease.
- A. What is the most realistic and appropriate nursing goal for an 80-year-old client with Parkinson’s disease?
- B. Return the client to usual activities of daily living.
- C. Maintain optimal function within the client’s limitations.
- D. Prepare the client for a peaceful and dignified death.
- E. Arrest progression of the disease process in the client.
Correct Answer: B
Rationale: Parkinson’s disease is progressive and irreversible, so maintaining optimal function within the client’s limitations is the most realistic goal, focusing on mobility, safety, and quality of life. Returning to normal activities, preparing for death, or arresting progression are unrealistic or inappropriate.
A client who has had a right below-the-knee amputation refers to himself as 'a freak' and 'old peg-leg.' What initial response by the nurse is most therapeutic?
- A. You are not a freak.'
- B. Lots of people have amputations and live a normal life.'
- C. You feel like a freak.'
- D. You shouldn't say that; you are very attractive.'
Correct Answer: C
Rationale: Reflecting the client's feelings ('You feel like a freak') validates their emotions, promoting therapeutic communication. Denying, normalizing, or reassuring dismisses their distress.
Following a CT scan with contrast medium, the nurse should give attention to:
- A. Maintaining bed rest for 8 hours
- B. Forcing fluids
- C. Observing the puncture site for hemorrhage
- D. Administering pain medication
Correct Answer: B
Rationale: Forcing fluids promotes excretion of contrast medium, reducing risk of renal toxicity. Bed rest and hemorrhage monitoring are not typically required.
Antibiotics are ordered for an adult who has a peptic ulcer. The client asks why antibiotics are prescribed. What should the nurse include when responding?
- A. Antibiotics are given to prevent secondary infections.
- B. Peptic ulcers are usually caused by bacteria.
- C. Antibiotics will create the environment necessary for the ulcers to heal.
- D. Antibiotics are given to prevent the infection from spreading to the bowel.
Correct Answer: B
Rationale: Peptic ulcers are often caused by Helicobacter pylori bacteria, and antibiotics eradicate the infection, promoting healing. They do not primarily prevent secondary infections, create healing environments, or stop bowel spread.
The nurse is teaching a client with a new diagnosis of asthma about fluticasone (Flovent). Which of the following statements by the client indicates a need for further teaching?
- A. I should rinse my mouth after using this inhaler.
- B. I should use this inhaler twice a day.
- C. I should report a sore throat to my doctor.
- D. I should use this inhaler when I have trouble breathing.
Correct Answer: D
Rationale: Using fluticasone as a rescue inhaler is incorrect, as it is a corticosteroid for maintenance therapy, not acute symptoms. Options A, B, and C are correct: rinsing prevents oral thrush, twice-daily use is standard, and sore throat may indicate infection.