Nokea
Which of the following questions is the priority for the nurse to ask the client?
- A. How do you manage your behavior?
- B. Do you have a criminal record?
- C. How do you get along with your peers at school?
- D. Do you have thoughts of harming yourself?
Correct Answer: D
Rationale: The correct answer is D. The nurse's priority is to assess for any immediate danger or harm to the client. Asking about thoughts of harming oneself is crucial in determining the client's safety. This question helps identify the client's risk of suicide and allows for timely intervention if needed. Choices A, B, and C focus on different aspects of the client's behavior and relationships, which are important but not as urgent as assessing for suicidal ideation. It is essential to address safety concerns first before exploring other areas.
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The nurse should monitor the client for which of the following complications?
- A. Contractions
- B. Hypertension
- C. Epigastric pain
- D. Vomiting
Correct Answer: A
Rationale: Contractions can indicate preterm labor, a potential complication after amniocentesis.
Which of the following actions should the nurse take?
- A. Place the client in a side-lying position prior to assessing the fetal heart rate.
- B. Measure the fundal height to determine the placement of the ultrasound stethoscope.
- C. Position the ultrasound stethoscope above the symphysis pubis to assess the fetal heart rate.
- D. Perform Leopold maneuvers prior to auscultating the fetal heart rate.
Correct Answer: C
Rationale: The correct answer is C: Position the ultrasound stethoscope above the symphysis pubis to assess the fetal heart rate. This is the correct action because placing the ultrasound stethoscope above the symphysis pubis allows for optimal detection of the fetal heart rate. This location is where the fetal heart sounds are best heard due to the proximity to the fetal heart. Placing the stethoscope in this location ensures accurate assessment of the fetal heart rate.
Choice A is incorrect because placing the client in a side-lying position is not necessary for assessing the fetal heart rate with an ultrasound stethoscope. Choice B is incorrect because measuring fundal height is not relevant to assessing the fetal heart rate. Choice D is incorrect because Leopold maneuvers are used to determine fetal position and presentation, not to assess the fetal heart rate.
Which of the following actions by the newly licensed nurse requires intervention by the staff nurse?
- A. Waits for 2 min between suctions
- B. Encourages the client to cough during suctioning
- C. Applies suction for 15 seconds
- D. Inserts the catheter without applying suction
Correct Answer: C
Rationale: Suctioning longer than 10-15 seconds risks hypoxia.
A nurse is providing an in-service about client evacuation during a fire. Which of the following clients should the nurse instruct the staff to evacuate first?
- A. A client who is ambulatory and receiving oxygen
- B. A client who has a fracture and is in balance suspension traction
- C. A client who is bedridden and wears a hearing aid
- D. A client who uses a wheelchair and is confused
Correct Answer: A
Rationale: The correct answer is A: A client who is ambulatory and receiving oxygen should be evacuated first during a fire. This client has limited mobility due to the oxygen supply and is at high risk for respiratory compromise in a fire. Evacuating this client first ensures their safety and prevents potential harm.
Choice B: A client with a fracture in balance suspension traction requires stabilization but is not in immediate danger during a fire.
Choice C: A bedridden client wearing a hearing aid can be safely evacuated after the oxygen-dependent client.
Choice D: A confused client using a wheelchair may need assistance but is not at immediate risk like the oxygen-dependent client.
Which of the following medications should the nurse administer?
- A. Bisacodyl 10 mg rectal suppository
- B. Magnesium hydroxide 30 mL PO
- C. Famotidine 20 mg PO
- D. Loperamide 4 mg PO
Correct Answer: A
Rationale: The correct answer is A: Bisacodyl 10 mg rectal suppository. Bisacodyl is indicated for immediate relief of constipation as a rectal suppository. It acts directly on the colon to stimulate peristalsis and promote bowel movement. The rectal route ensures faster onset of action compared to oral medications, making it suitable for a patient needing immediate relief. Magnesium hydroxide (B) is a laxative taken orally, which may not provide quick relief. Famotidine (C) is for acid reflux, not constipation. Loperamide (D) is an antidiarrheal agent, not appropriate for constipation.