Nokea
Which of these clients would be appropriate to assign to a practical nurse (PN)?
- A. A trauma victim with multiple lacerations and requires complex dressings
- B. An elderly client with cystitis and an indwelling urethral catheter
- C. A confused client whose family complains about the nursing care 2 days after surgery
- D. A client admitted for possible transient ischemic attack with unstable neurological signs
Correct Answer: B
Rationale: This is a stable client, with predictable outcome and care and minimal risk for complications.
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A mother brings her 1-month-old son to the clinic for a well-baby visit. The child has a moderately severe hypospadias that was seen by a urologist in the newborn nursery. The mother is upset that the doctors would not circumcise her son before he was discharged. What information should the nurse include when responding to the mother?
- A. The foreskin should not be removed because it will be used in the repair of the hypospadias.
- B. The child's condition did not allow for elective surgery. It will be done at a later date when he is stronger.
- C. Circumcision is a surgical procedure. Because he will have surgery in the near future, it will be done at the same time to avoid two surgeries close together.
- D. The procedure was not done because circumcision is medically unnecessary, not because he has a hypospadias.
Correct Answer: A
Rationale: Hypospadias repair often uses foreskin tissue, so circumcision is avoided to preserve it for surgical correction, addressing the mother's concern.
A Hispanic client confides in the nurse that she is concerned that staff may give her newborn the 'evil eye.' The nurse should communicate to other personnel that the appropriate approach is to
- A. Touch the baby after looking at him
- B. Talk very slowly while speaking to him
- C. Avoid touching the child
- D. Look only at the parents
Correct Answer: A
Rationale: In many cultures, an 'evil eye' is cast when looking at a person without touching him. Thus, the spell is broken by touching while looking or assessing.
The doctor has ordered two medications to be given intramuscularly. The nurse should:
- A. Ask the doctor to clarify the order.
- B. Give one injection, wait 30 minutes, and give the other.
- C. Determine whether the medications can be combined.
- D. Administer the injections, one in each hip.
Correct Answer: C
Rationale: The nurse must check if the medications are compatible for combination in one syringe to minimize injections. Administering separately without checking or in specific sites is premature.
In assessing a post partum client, the nurse palpates a firm fundus and observes a constant trickle of bright red blood from the vagina. What is the most likely cause of these findings?
- A. Uterine atony
- B. Genital lacerations
- C. Retained placenta
- D. Clotting disorder
Correct Answer: B
Rationale: Genital lacerations. Continuous bleeding in the absence of a boggy fundus indicates undetected genital tract lacerations.
The nurse is caring for four antepartum clients. Which client should the nurse see first?
- A. Client with hyperemesis gravidarum who is currently vomiting (9%)
- B. Client with molar pregnancy who has dark brown vaginal discharge (8%)
- C. Client with suspected ectopic pregnancy who has abdominal and shoulder pain (71%)
- D. Client with threatened miscarriage who says, 'I am a Jehovah's Witness.' (10%)
Correct Answer: C
Rationale: A suspected ectopic pregnancy is a medical emergency due to the risk of rupture and internal bleeding, which can be life-threatening. Abdominal and shoulder pain are hallmark symptoms, indicating possible referred pain from diaphragmatic irritation. This client requires immediate assessment and intervention, prioritizing over hyperemesis gravidarum (which, while serious, is less immediately life-threatening), molar pregnancy (which needs monitoring but is not an acute emergency), and threatened miscarriage (which requires evaluation but is less urgent without active bleeding or pain).