Nokea
Which of the following steps is the final step that is used during the physical assessment of the abdomen?
- A. Inspection
- B. Light palpation
- C. Deep palpation
- D. Percussion
Correct Answer: C
Rationale: The standard sequence for abdominal assessment is inspection, auscultation, percussion, and palpation (light then deep). Deep palpation is the final step to assess for organ size or abnormalities.
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Which of these clients is at greatest risk for falls?
- A. A 77 year old female client in a client room that has low glare floors.
- B. An 87 year old female client in a client room that has low glare floors.
- C. A 27 year old sedated male client.
- D. A 37 year old male client with impaired renal perfusion.
Correct Answer: B
Rationale: An 87-year-old female is at the greatest risk for falls due to age-related factors like decreased mobility, balance issues, and potential comorbidities, compared to younger or less impaired clients.
Methylergonovine maleate is prescribed for a woman who has just delivered a healthy newborn. Which is the priority assessment to complete before administering the medication?
- A. Lochia
- B. Uterine tone
- C. Blood pressure
- D. Deep tendon reflexes
Correct Answer: C
Rationale: Methylergonovine maleate, an oxytocic, is an agent used to prevent or control postpartum hemorrhage by contracting the uterus. The immediate dose is administered intramuscularly, and then, if still needed, it is administered orally. It causes uterine contractions and may elevate the blood pressure. A priority assessment before administration of methylergonovine maleate is blood pressure. Methylergonovine maleate is to be administered cautiously in the presence of hypertension, and the primary health care provider should be notified if hypertension is present. Options 1 and 2 are general components of care in the postpartum period. Option 4 is most specifically related to the administration of magnesium sulfate.
Place the following steps for mixing NPH and regular insulin in the proper sequential order from # 1 to # 6 below. #1 - Prep the top of the shorter acting insulin with an alcohol swab #2 - Inject air that is equal to the ordered dosage of the shorter acting insulin using the same insulin syringe. #3 - Withdraw the ordered dosage of the shorter acting insulin using the same insulin syringe. #4 - Prep the top of the longer acting insulin vial with an alcohol swab. #5 - Inject air that is equal to the ordered dosage of the longer acting insulin using the insulin syringe. #6 - Withdraw the ordered dosage of the longer acting insulin using the same insulin syringe.
- A. 1,5,4,2,3,6
- B. 4,3,2,6, 1,5
- C. 4,2,5,3, 1,6
- D. 1,5,3,6,4,2
Correct Answer: A
Rationale: The correct sequence is: 1) Prep short-acting insulin vial, 2) Inject air into short-acting vial, 3) Withdraw short-acting insulin, 4) Prep long-acting insulin vial, 5) Inject air into long-acting vial, 6) Withdraw long-acting insulin to avoid contamination.
A client has undergone a vaginal hysterectomy. Which interventions should the nurse include in the client's nursing care plan to decrease the risk of deep vein thrombosis or thrombophlebitis? Select all that apply.
- A. Use pneumatic compression boots.
- B. Maintain bed rest for 24 to 48 hours.
- C. Assist with range-of-motion leg exercises.
- D. Elevate the knees with the knee gatch on the bed.
- E. Remove antiembolism stockings twice daily for assessment.
Correct Answer: A,C,E
Rationale: The client is at risk for deep vein thrombosis or thrombophlebitis after this surgery, as for any other major surgery. For this reason, the nurse implements measures that will prevent this complication. Ambulation, pneumatic compression boots, range-of-motion exercises, and antiembolism stockings are all helpful. The nurse should avoid elevating the knees using the knee gatch in the bed, which inhibits venous return and places the client more at risk for deep vein thrombosis or thrombophlebitis.
The nurse is providing bottle-feeding instructions to the mother of a newborn infant. The nurse provides instructions regarding the amount of formula to be given, knowing that what is the approximate stomach capacity for a newborn?
- A. 5 to 10 mL
- B. 10 to 20 mL
- C. 30 to 90 mL
- D. 75 to 100 mL
Correct Answer: B
Rationale: The stomach capacity of a newborn is approximately 10 to 20 mL. It is 30 to 90 mL for a 1-week-old infant and 75 to 100 mL for a 2- to 3-week-old infant.