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A client in her first trimester of pregnancy is scheduled for an ultrasound. Which of the following would not be a reason for an ultrasound at this stage? A Determine fetal position. B Detect multiple gestations. C Detect maternal abnormalities. D Confirm pregnancy. ________________________________________ Correct Answer: A Choice A rationale: Fetal position during the first trimester is not definitively determined through ultrasound. While the gestational sac and fetal pole can b...

The nurse is teaching a client how to self-administer low-molecular-weight heparin subcutaneously. Which instruction should the nurse include? A Massage the injection site to increase absorption. B Rotate injections between the abdomen and gluteal areas. C Expel the air in the prefilled syringe prior to injection. D Inject in abdominal area at least 2 inches from the umbilicus. ________________________________________ Correct Answer: D Choice A Reason: Massaging the injection site c...

A nurse is collecting data from a client who is receiving vancomycin for a Clostridium difficile infection. Which of the following findings is the priority for the nurse to report to the provider? A Two loose stools in the past 24 hr B WBC 11,000/mm3 C Creatinine 3.1 mg/dL D Heart rate 104/min ________________________________________ Correct Answer: C A. While diarrhea is a concern, it is a common side effect of vancomycin and may not be the highest priority. B. Elevated whit...

A nurse is assisting in the care of a client who is receiving gentamicin 60 mg via intermittent IV bolus. Available is gentamicin 60 mg/100 mL to infuse over 75 min. The nurse should ensure the IV pump is set to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) ________________________________________ Correct Answer: ["80"] To calculate the infusion rate for gentamicin, the nurse should use the following f...

A nurse is caring for a client who has dementia. Which of the following actions should the nurse take to promote communication? A Face the client at eye level when communicating. B Offer correction of incorrect client statements. C Reorient the client to date and time with each encounter. D Avoid using gestures when communicating with the client. ________________________________________ Correct Answer: A Face the client at eye level when communicating.

The nurse is conducting a prenatal class explaining the various activities that will occur within the first few hours after birth. The nurse determines the session is successful when the couples correctly choose which reason for the use of an antibiotic ointment. A Prevent infection of the umbilical cord B Prevent infection of the eyes from vaginal bacteria C Protect tear ducts from vaginal bacteria D Protect the urethra from fecal material ________________________________________ Co...

A nurse is caring for a client who has a new prescription for warfarin. The nurse should use the results of which of the following diagnostic tests to monitor the effect of this therapy? A Prothrombin time (PT) B Platelet count C White blood cell count (WBC) D Activated partial thromboplastin time (aPTT) ________________________________________ Correct Answer: A a. Prothrombin time (PT): Warfarin affects the extrinsic pathway of the coagulation cascade, and PT is the primary dia...

The nurse is educating a patient with phlebitis of the left leg. What alternative therapy should this patient avoid until the condition is resolved? A Yoga. B Therapeutic massage. C Acupressure. D Acupuncture. ________________________________________ Correct Answer: B Choice A rationale: Yoga involves gentle stretching and may not directly impact the phlebitis. Choice B rationale: Therapeutic massage could potentially dislodge a clot in the leg, leading to a dangerous condition ...

The nurse completes visual inspection of a client's abdomen. What technique should the nurse perform next in the abdominal examination? A Auscultation. B Percussion. C Light palpation. D Deep palpation. ________________________________________ Correct Answer: A Choice A rationale: After visual inspection, the next step typically involves auscultation, which allows the nurse to listen for bowel sounds and gather information about gastrointestinal function. Choice B rationale: P...

A client is admitted to a mental health unit because of mild depression. When asked, the client denies suicidal ideation, but the nurse reads in the psychosocial assessment that there were attempts to overdose on aspirin 5 years earlier. Which nursing action is most important for this client? Correct Answer A Orient the client to activities on the unit. B Document suicide precautions on the shift report. C Assign the client to a semiprivate room. D Obtain a verbal no-suicide contract with t...