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1. A client who is at 36 weeks of gestation is being taught about nonstress testing. Which of the following statements should the nurse include in the teaching?
- A. This test will determine the length of your cervix.
- B. You will have your blood pressure taken frequently during the test.
- C. You should press the handheld button when you feel your baby move.
- D. This test will take about 5 minutes to complete.
Correct answer: C
Rationale: The correct answer is C. In a nonstress test, the client is required to press a handheld button whenever fetal movement is felt, which is then recorded on the monitor. This action helps assess the baby's heart rate in response to its movements, providing valuable information about the baby's well-being. Choices A, B, and D are incorrect because the nonstress test does not involve determining the length of the cervix, monitoring blood pressure, or being completed in 5 minutes. These aspects are not part of the nonstress testing procedure and are unrelated to the purpose of the test.
2. What is the first step in managing a client with delirium?
- A. Administer sedative medication to calm the client
- B. Identify any reversible causes of delirium
- C. Limit environmental stimulation to reduce anxiety
- D. Administer antipsychotic medication to control behavior
Correct answer: B
Rationale: The correct first step in managing a client with delirium is to identify any reversible causes of delirium. This is crucial because addressing the underlying cause can help in resolving delirium more effectively. Administering sedative or antipsychotic medications without addressing the root cause may not be helpful and can even worsen the condition. Limiting environmental stimulation, although important, is not the primary step in managing delirium.
3. A nurse is caring for a client who has been experiencing chronic pain. Which of the following interventions should the nurse implement?
- A. Provide the client with distractions such as television
- B. Administer pain medication around the clock
- C. Teach the client relaxation techniques
- D. Perform massage therapy on the client
Correct answer: C
Rationale: The correct intervention for a client experiencing chronic pain is to teach relaxation techniques. This helps the client manage pain more effectively by reducing stress and anxiety, which can contribute to the perception of pain. Providing distractions like television (Choice A) may offer temporary relief but does not address the underlying issue of chronic pain. Administering pain medication around the clock (Choice B) may lead to dependency and not promote holistic pain management. Massage therapy (Choice D) can be beneficial but may not be as effective as teaching relaxation techniques in the long term for managing chronic pain.
4. A client diagnosed with gout is receiving dietary instruction from a nurse. What dietary advice should be provided?
- A. Limit intake of fresh fruits and uncooked vegetables
- B. Limit intake of red meat and shellfish
- C. Limit intake of dairy products
- D. Increase intake of leafy greens
Correct answer: B
Rationale: The correct answer is to limit the intake of red meat and shellfish. These foods are high in purines, which can increase uric acid levels and trigger gout flare-ups. Fresh fruits, uncooked vegetables, dairy products, and leafy greens are generally not associated with exacerbating gout symptoms and do not need to be significantly restricted in the diet of someone with gout.
5. A healthcare professional is preparing to administer a blood transfusion. What is the first step?
- A. Administer the blood through an IV push
- B. Verify that the client's blood type matches the blood product
- C. Ensure the client has eaten before the transfusion
- D. Administer a diuretic before starting the transfusion
Correct answer: B
Rationale: The correct first step before administering a blood transfusion is to verify that the client's blood type matches the blood product. This step is crucial to prevent transfusion reactions due to incompatibility. Choice A is incorrect because blood should not be administered through an IV push for a blood transfusion. Choice C is incorrect because it is not necessary for the client to eat before a blood transfusion. Choice D is incorrect because administering a diuretic is not a standard practice before starting a blood transfusion.
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