Nokea
A nurse is teaching a prenatal class about infection prevention at a community center.
Which of the following statements by a client indicates an understanding of the teaching?
- A. I should take antibiotics when I have a virus.
- B. I can visit my nephew who has chickenpox 5 days after the sores have crusted.
- C. I should avoid cleaning my cat's litter box during pregnancy.
- D. I do not need to get the flu vaccine while I am pregnant.
Correct Answer: C
Rationale: The correct answer is C: "I should avoid cleaning my cat's litter box during pregnancy." This statement shows an understanding of the teaching because cleaning a cat's litter box can expose a pregnant person to toxoplasmosis, a harmful parasite that can cause complications during pregnancy. Avoiding this task is a precautionary measure recommended to protect the health of the mother and the unborn child.
Explanation of why other choices are incorrect:
A: "I should take antibiotics when I have a virus." - Antibiotics are not effective against viruses, so this statement shows a misunderstanding of when antibiotics should be used.
B: "I can visit my nephew who has chickenpox 5 days after the sores have crusted." - Chickenpox is highly contagious, so visiting someone with active chickenpox can put the pregnant person at risk.
D: "I do not need to get the flu vaccine while I am pregnant." - The flu vaccine is recommended during pregnancy to protect both the pregnant
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A nurse is caring for a client who was at 33 weeks of gestation following an amniocentesis.
Which complication should the nurse monitor for?
- A. Contractions
- B. Increased fetal movement
- C. Hypertension
- D. Hypoglycemia
Correct Answer: A
Rationale: The correct answer is A: Contractions. Nurses should monitor for contractions as they could indicate preterm labor or other complications. Increased fetal movement (B) is not necessarily a complication but could be a sign of fetal well-being. Hypertension (C) is important to monitor but may not be directly related to the current situation. Hypoglycemia (D) is also important but not typically a primary concern in this situation.
A nurse is caring for a client who has diabetes mellitus and is receiving long-acting insulin for blood glucose management.
Which type of insulin should the nurse anticipate administering?
- A. Glargine insulin.
- B. Regular insulin.
- C. NPH insulin.
- D. Insulin aspart.
Correct Answer: A
Rationale: The correct answer is A: Glargine insulin because it is a long-acting insulin with a duration of action of up to 24 hours, providing a basal level of insulin throughout the day. It is typically administered once daily at the same time each day to maintain stable blood glucose levels. Regular insulin (B) is short-acting and is usually given before meals. NPH insulin (C) is intermediate-acting and has a peak action of 4-12 hours. Insulin aspart (D) is a rapid-acting insulin used for mealtime coverage. In this scenario, the nurse should anticipate administering Glargine insulin for its long-acting, basal properties.
A nurse is providing teaching about home safety to an adult child of an older adult client who is postoperative following knee replacement surgery.
Which of the following instructions should the nurse include?
- A. Mark the edges of the doorway to the house with tape.
- B. Remove loose rugs from the home to prevent falls.
- C. Place soft cushions on all chairs to reduce discomfort.
- D. Install bright overhead lighting in the bedroom only.
Correct Answer: B
Rationale: The correct answer is B: Remove loose rugs from the home to prevent falls. This instruction is crucial in preventing falls, especially for elderly individuals who may have balance issues. Loose rugs are a common tripping hazard and removing them can significantly reduce the risk of falls. Marking the edges of the doorway with tape (A) may not be effective in preventing falls as it does not address the actual hazards. Placing soft cushions on all chairs (C) does not directly address fall prevention and may not be suitable for all individuals. Installing bright overhead lighting in the bedroom only (D) is important for visibility but does not address other fall risks in the home.
A nurse is providing care for a client following a thoracentesis.
If the client develops a pneumothorax, which of the following assessment findings should the nurse expect?
- A. Stridor
- B. Pain on inhalation chest pain that worsens when you breathe or pleuritic pain
- C. Friction rub
- D. Bradycardia
Correct Answer: B
Rationale: The correct answer is B: Pain on inhalation chest pain that worsens when you breathe or pleuritic pain. A pneumothorax is the presence of air in the pleural space, causing lung collapse. When air enters this space, it creates pressure, leading to sharp chest pain that worsens with breathing (pleuritic pain). This occurs because the air-filled space prevents the lungs from expanding fully during inhalation, causing discomfort. Stridor (choice A) is a high-pitched sound indicating upper airway obstruction, not typically associated with a pneumothorax. Friction rub (choice C) indicates inflammation of the pleura, not specific to a pneumothorax. Bradycardia (choice D) is unlikely in pneumothorax, as it is more commonly associated with conditions affecting the heart rate.
A nurse is performing a neurological examination on a client as part of a complete physical assessment. The nurse should identify that cranial nerve XI(11) is intact when the client performs which of the following actions?
- A. Shrugs his shoulders
- B. Smiles symmetrically
- C. Closes his eyes tightly
- D. Identifies a familiar scent
Correct Answer: A
Rationale: The correct answer is A: Shrugs his shoulders. Cranial nerve XI, also known as the accessory nerve, controls the movement of the trapezius and sternocleidomastoid muscles, which are responsible for shoulder shrugging. By asking the client to shrug his shoulders, the nurse can assess the integrity of cranial nerve XI.
Choices B, C, and D are incorrect because they are associated with other cranial nerves. Smiling symmetrically is controlled by cranial nerve VII (facial nerve), closing eyes tightly is controlled by cranial nerve V (trigeminal nerve), and identifying a familiar scent is related to cranial nerve I (olfactory nerve).