Nokea
Which of the following situations is most likely to produce sepsis in the neonate?
- A. Maternal diabetes
- B. Prolonged rupture of membranes
- C. Cesarean delivery
- D. Precipitous vaginal birth
Correct Answer: B
Rationale: Prolonged rupture of membranes. Premature rupture of the membranes (PROM) is a leading cause of newborn sepsis. After 12-24 hours of leaking fluid, measures are taken to reduce the risk to mother and the fetus/newborn.
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An adult client is found to be unresponsive on morning rounds. After checking for responsiveness and calling for help, the next action that should be taken by the nurse is to:
- A. check the carotid pulse
- B. deliver 5 abdominal thrusts
- C. give 2 rescue breaths
- D. ensure an open airway
Correct Answer: D
Rationale: According to the ABCs of CPR, the first step in rescuing an unresponsive victim after checking responsiveness and calling for help is to open the victim's airway.
A client has many delusions. As the nurse helps the client prepare for breakfast the client comments 'Don't waste good food on me. I'm dying from this disease I have.' The appropriate response would be
- A. You need some nutritious food to help you regain your weight.'
- B. None of the laboratory reports show that you have any physical disease.'
- C. Try to eat a little bit, breakfast is the most important meal of the day.'
- D. I know you believe that you have an incurable disease.'
Correct Answer: D
Rationale: This response does not challenge the client’s delusional system and thus forms an alliance by providing reassurance of desire to help the client.
The nurse is talking with a client who has type 1 diabetes mellitus and is receiving newly prescribed continuous subcutaneous insulin infusion therapy via an infusion pump. Which of the following statements by the client would indicate a correct understanding of the therapy?
- A. I will no longer need to test my blood glucose level throughout the day.
- B. I will no longer require an extra dose of insulin before my meals.
- C. My blood glucose levels should be more consistent throughout the day.
- D. The infusion set of my insulin pump should be changed daily.
Correct Answer: C
Rationale: Insulin pumps (C) provide steady insulin delivery, improving glucose stability. Glucose monitoring (A) and bolus doses (B) are still needed, and infusion sets are changed every 2-3 days, not daily (D).
The nurse is assisting in planning care for a client experiencing an acute attack of Ménière disease. Which action is a high priority to include in the plan of care?
- A. Initiate fall precautions
- B. Keep the emesis basin at bedside
- C. Provide a quiet environment
- D. Start IV fluids
Correct Answer: C
Rationale: A quiet environment (C) reduces sensory overload, a priority in Ménière disease attacks. Fall precautions (A), emesis basin (B), and IV fluids (D) are supportive but less critical.
The nurse is caring for a client with bulimia nervosa. It would be a priority for the nurse to
- A. place limits on the time allowed for client meals
- B. check on the client at irregular intervals during the overnight hours
- C. monitor the client for 1 to 2 hours after each meal
- D. discuss complications associated with bulimia nervosa with the client
Correct Answer: C
Rationale: Monitoring for 1-2 hours after meals (C) prevents purging, a priority in bulimia management. Time limits (A) may increase anxiety, overnight checks (B) are less relevant, and discussing complications (D) is educational but not immediate.