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While collecting data from pregnant clients in the obstetric clinic, the nurse should alert the health care provider to see which client first?
- A. First-trimester client who reports frequent nausea and vomiting
- B. Second-trimester client with dysuria and urinary frequency
- C. Second-trimester client with obesity who reports decrease in fetal movement
- D. Third-trimester client with right upper quadrant pain and nausea
Correct Answer: C
Rationale: Decreased fetal movement in the second trimester suggests potential fetal distress, requiring urgent evaluation. Nausea, UTI symptoms, and third-trimester pain are concerning but less immediately critical.
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While reviewing the chart of an elderly client, the nurse notes that the last recorded temperature for the preceding shift was 104°. There is no documented intervention. The nurse should:
- A. Check the doctor's orders for an antipyretic.
- B. Ask the client whether he has received any medication for his fever.
- C. Call the nurse at home to validate whether the medication was given.
- D. Retake the client's temperature.
Correct Answer: D
Rationale: Retaking the temperature verifies the current status, as the fever may have resolved. Checking orders or asking the client assumes the fever persists, and calling the nurse is impractical.
The nurse is caring for a client with a head injury who has increased ICP. The physician plans to reduce the cerebral edema by reversing dilation of cerebral blood vessels. Which physician prescription would the nurse expect to accomplish this?
- A. Hyperventilation per mechanical ventilation
- B. Insertion of a ventricular shunt
- C. Furosemide (Lasix)
- D. Methylprednisolone (Solu-Medrol)
Correct Answer: A
Rationale: Hyperventilation is utilized to decrease the PCO2 to 27-30, producing cerebral blood vessel constriction. Answers B, C, and D can decrease cerebral edema, but not by constriction of cerebral blood vessels; therefore, they are wrong.
Which type of accidental poisoning would the nurse expect to occur in children under age 6?
- A. Oral ingestion
- B. Topical contact
- C. Inhalation
- D. Eye splashes
Correct Answer: A
Rationale: Oral ingestion. Young children are most likely to ingest toxic substances due to their exploratory behavior.
The nurse is reinforcing teaching about nutrition with the parents of a 6-year-old client with cystic fibrosis. Which recommended diet should the nurse include?
- A. High calorie, high protein
- B. High carbohydrate, low fiber
- C. Low fat, low sodium
- D. Low phosphate, low protein
Correct Answer: A
Rationale: Cystic fibrosis requires a high-calorie, high-protein diet to support growth and compensate for malabsorption. Other diets do not meet the increased nutritional demands.
The nurse in the long-term care facility discovers a client with dementia wandering in the hallway during the night. Which of the following statements would be most appropriate for the nurse to make?
- A. What are you doing in the hallway? It is not time to wake up yet
- B. You should stop walking in the hallway at night because you might fall
- C. You are in the long-term care facility. Let us go back to your room together
- D. Ask a staff member to accompany you the next time you wish to leave your room
Correct Answer: C
Rationale: Orienting the client and gently redirecting them to their room is calming and safe. Questioning, warning, or instructing may confuse or agitate a client with dementia.