Nokea
The triage nurse for a women's health center receives a phone call from each of the following women.
Which woman should be directed to come to the health care facility IMMEDIATELY?
- A. A multipara woman who is four weeks pregnant and reporting unilateral, dull abdominal pain.
- B. A primipara woman who is seven weeks pregnant and reporting an increase in whitish vaginal secretions.
- C. A primigravida woman who is five weeks gestation and is having vaginal spotting and some cramping.
- D. A multigravida woman who is six weeks pregnant and reporting frank, red vaginal bleeding with moderate cramps.
Correct Answer: A
Rationale: Strategy: Determine the least stable client. (1) correct-needs to be evaluated for an ectopic pregnancy (2) expect during first trimester of pregnancy (3) symptomatic of threatened abortion; instruct to decrease activity (4) symptoms of spontaneous abortion; instruct client to save and count pads
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A client with polyuria, polydipsia, and polyphagia is diagnosed with diabetes mellitus. The nurse would expect that these symptoms are related to
- A. Hypoglycemia
- B. Hyperglycemia
- C. Hyperparathyroidism
- D. Hyperthyroidism
Correct Answer: B
Rationale: Polyuria, polydipsia, and polyphagia are classic symptoms of hyperglycemia in diabetes mellitus. Hypoglycemia , hyperparathyroidism , and hyperthyroidism do not typically cause this triad.
The nurse should observe for side effects associated with the use of bronchodilators. A common side effect of bronchodilators is:
- A. Tinnitus
- B. Tachycardia
- C. Ataxia
- D. Hypotension
Correct Answer: B
Rationale: Tachycardia is a common side effect of bronchodilators, such as beta-agonists, due to their stimulatory effect on the sympathetic nervous system.
An 8 year-old client is admitted to the hospital for surgery. The child's parent reports the allergies listed below. Which of these allergies should all health care personnel be aware of?
- A. Shellfish
- B. Molds
- C. Balloons
- D. Perfumed soap
Correct Answer: C
Rationale: Allergy to balloons indicates a latex allergy. All personnel in contact with the child will need to be aware of this condition and use non-latex gloves.
The recent increase in the reported cases of active tuberculosis (TB) in the United States is attributed to which factor?
- A. The increased homeless population in major cities
- B. The rise in reported cases of positive HIV infections
- C. The migration patterns of people from foreign countries
- D. The aging of the population located in group homes
Correct Answer: B
Rationale: The rise in reported cases of positive HIV infections. Between 1985 and 2002 there has been a significant increase in the reported cases of TB. The increase was most evident in cities with a high incidence of positive HIV infection. Positive HIV infection currently is the greatest known risk factor for reactivating latent TB infections.
The nurse is to open a sterile package. How should the nurse plan to open the first flap?
- A. Toward the nurse
- B. Away from the nurse
- C. To the right side
- D. To the left side
Correct Answer: B
Rationale: Opening the first flap away from the nurse maintains sterility by preventing hands from passing over the sterile field. Opening toward the nurse or to the sides risks contamination.