A client who is at full-term gestation is in active labor and complains of a cramp in her leg. Which intervention should the nurse implement?

A. Massage the calf and foot

B. Elevate the leg above the heart

C. Check the pedal pulse in the affected leg

D. Extend the leg and flex the foot

Correct Answer: D
Rationale: The correct intervention for a client in active labor complaining of a leg cramp is to extend the leg and flex the foot. This action helps stretch the muscles that are cramping, providing relief. Massaging the calf and foot (Choice A) may not be as effective for relieving the cramp. Elevating the leg above the heart (Choice B) is not indicated for a leg cramp. Checking the pedal pulse in the affected leg (Choice C) is unrelated to addressing the leg cramp.

Which of the following best describes the role of insulin in the body?

• A. Insulin helps break down glucose into energy for the body
• B. Insulin facilitates the movement of glucose into cells
• C. Insulin converts excess glucose into fat for storage
• D. Insulin increases the breakdown of protein into amino acids

Correct Answer: B
Rationale: The correct answer is B: Insulin facilitates the movement of glucose into cells. Insulin is a hormone that helps regulate blood sugar levels by promoting the uptake of glucose from the bloodstream into cells, where it can be used for energy production. Choice A is incorrect because insulin doesn't break down glucose but rather helps cells take up glucose. Choice C is incorrect as insulin does not directly convert glucose into fat; excess glucose is stored as fat by other processes. Choice D is incorrect as insulin does not increase the breakdown of protein into amino acids; its primary role is in glucose metabolism.

A client post-thoracotomy is complaining of severe pain with deep breathing and coughing. What should the nurse encourage the client to do to manage the pain and prevent respiratory complications?

• A. Hold a pillow against the chest while coughing (splinting).
• B. Take shallow breaths to avoid pain.
• C. Increase the dose of pain medication.
• D. Avoid deep breathing exercises.

Correct Answer: A
Rationale: Splinting the chest with a pillow helps manage pain during deep breathing and coughing, which is essential to prevent respiratory complications such as atelectasis or pneumonia after thoracic surgery. Holding a pillow against the chest while coughing (splinting) supports the incision site and reduces the pain associated with deep breathing and coughing. Encouraging shallow breaths (Choice B) can lead to respiratory complications due to inadequate lung expansion. Increasing pain medication (Choice C) should be done based on healthcare provider orders and not solely for this situation. Avoiding deep breathing exercises (Choice D) can worsen respiratory function and increase the risk of complications.

While turning and positioning a bedfast client, the PN observes that the client is dyspneic. Which action should the PN take first?

• A. Apply a pulse oximeter
• B. Measure blood pressure
• C. Notify the charge nurse
• D. Observe pressure areas

Correct Answer: C
Rationale: Notifying the charge nurse promptly is the priority when a bedfast client is dyspneic. Dyspnea can indicate a serious problem that requires immediate assessment and intervention. Contacting the charge nurse ensures timely assistance and appropriate actions to address the client's condition. Applying a pulse oximeter or measuring blood pressure may provide valuable data, but the priority is prompt communication with the charge nurse to ensure quick intervention. Observing pressure areas, while important for overall client care, is not the most immediate action needed when a client is experiencing dyspnea.

A client post-lobectomy is placed on mechanical ventilation. The nurse notices the client is fighting the ventilator. What should the nurse do first?

• A. Increase the sedation as prescribed.
• B. Manually ventilate the client using an ambu bag.
• C. Check the ventilator settings and alarms.
• D. Suction the client’s airway.

Correct Answer: C
Rationale: The correct first action for the nurse to take when a client is fighting the ventilator is to check the ventilator settings and alarms. This step is crucial to ensure that the ventilator is functioning correctly and providing the necessary support to the client. Increasing sedation (Choice A) should only be considered after confirming that the ventilator settings are appropriate. While manually ventilating the client (Choice B) may be required in some cases, it is not the initial action to take. Suctioning the client's airway (Choice D) is not the priority in this situation, where the primary concern is addressing the client's struggle with the ventilator.