a nurse midwife performing a vaginal examination of a client who suspects that she is pregnant documents the presence of the chadwick sign the nurse r a nurse midwife performing a vaginal examination of a client who suspects that she is pregnant documents the presence of the chadwick sign the nurse r
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Nursing Elites

NCLEX NCLEX-PN

Health Promotion and Maintenance NCLEX Questions

1. When a nurse-midwife, performing a vaginal examination of a client who suspects that she is pregnant, documents the presence of the Chadwick sign, what does this indicate?

Correct answer: That the cervix appears violet

Rationale: The correct interpretation of the Chadwick sign is that the cervix appears violet in color. This sign is a probable sign of pregnancy, characterized by the violet coloration of the cervix due to increased vascularity of the pelvic organs. It is not a definitive positive sign of pregnancy but rather a probable one. Choices B and D are incorrect as cervical softening is known as the Goodell sign, and thinning of the cervix is referred to as the Hegar sign. These signs are also probable signs of pregnancy, but they do not specifically indicate the Chadwick sign.

2. Which symptom is the client who self-administered an overdose of acetaminophen most likely to exhibit?

Correct answer: Jaundiced conjunctiva

Rationale: When a client self-administers an overdose of acetaminophen, the liver is primarily affected. Jaundiced conjunctiva, which is yellowing of the eyes, is a common symptom of liver damage. Pink frothy sputum is typically associated with conditions like pulmonary edema, not acetaminophen overdose. Seizure activity is not a common symptom of acetaminophen overdose but can be seen in other toxicities. Diaphoresis and fever are more generalized symptoms and not specific to acetaminophen overdose.

3. The nurse notices that a family is waiting at the nursing station desk for its loved one to be brought to the unit for admission during a change-of-shift report. The nurse should:

Correct answer: request that the family wait for its loved one in the client’s room and wait to resume the report until the family has left the desk area.

Rationale: To protect the privacy of clients and the confidentiality of the information shared in a change-of-shift report, the family should be asked to wait in the client’s room. This ensures that sensitive information is not overheard. The report should be resumed only after the family has left the desk area to maintain confidentiality. Choice B is incorrect as bringing coffee does not address the issue of maintaining confidentiality. Choice C is incorrect as standing or sitting in the station does not prevent the family from overhearing confidential information. Choice D is incorrect as the Emergency Department waiting room is not the appropriate setting for waiting during a unit admission.

4. After undergoing gastric resection, which of the following meals is most likely to cause rapid emptying of the stomach?

Correct answer: a high-carbohydrate meal

Rationale: After gastric resection, meals high in carbohydrates are more likely to cause rapid emptying of the stomach. Carbohydrates stimulate the release of gastrin, which accelerates gastric emptying. In contrast, high-fat and high-protein meals tend to delay gastric emptying. While a large meal can slow down gastric emptying, the specific nutrient content, such as high carbohydrates, plays a significant role in promoting rapid emptying. Therefore, a high-carbohydrate meal is the correct choice as it is most likely to lead to rapid gastric emptying compared to the other options.

5. The nurse overhears two nursing students talking about a client in the cafeteria. What should the nurse do first?

Correct answer: Instruct the students that this is a violation of HIPAA.

Rationale: The correct answer is to instruct the students that discussing a client in a public area like the cafeteria violates HIPAA regulations. This is important to educate the students about patient confidentiality and the consequences of breaching it. Reporting to the nursing supervisor or faculty should come after addressing the students directly. Writing up a variance report is not the immediate action needed in this situation, as educating the students about their mistake should be the priority. It is essential to address the issue at the source by educating the students first rather than escalating the matter to supervisors or faculty immediately.

Similar Questions

A nurse in a medical-surgical unit overhears the nursing staff openly discussing a client and stating that the client is uncooperative and a real pain to care for. The nurse would most appropriately manage this issue by taking which action?
Melissa Smith came to the Emergency Department in the last week before her estimated date of confinement complaining of headaches, blurred vision, and vomiting. Suspecting PIH, the nurse should best respond to Melissa’s complaints with which of the following statements?
Which of the following clients would be most appropriate for an LPN to assign to a nursing assistant?
A nurse who recently learned she is pregnant has just received client assignments for the day. Which client assignment should the nurse question as being inappropriate?
Client self-determination is the primary focus of:

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