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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. A nurse in a provider's office is reinforcing discharge teaching with a client who is postoperative following cataract removal from one eye. Which of the following instructions should the nurse include?
- A. Use eye drops to soothe dryness
- B. Avoid rubbing the eye
- C. Sleep on the side of the affected eye
- D. Avoid lying on the affected side
Correct answer: D
Rationale: After cataract surgery, it is essential to avoid lying on the affected side to reduce pressure and promote healing. Sleeping on the side of the affected eye (Choice C) may increase pressure on the eye, leading to complications. While using eye drops to soothe dryness (Choice A) is generally recommended postoperatively, it is not as crucial as avoiding pressure on the eye. Rubbing the eye (Choice B) should be avoided to prevent irritation and potential damage, but it is not as critical as avoiding pressure on the affected eye.
3. A nurse is reviewing the plan of care for a client who is receiving chemotherapy for cancer. Which of the following interventions should the nurse include to prevent infection?
- A. Encourage the client to eat high-protein foods
- B. Encourage the client to drink 2 liters of fluid daily
- C. Instruct the client to use a soft toothbrush
- D. Instruct the client to use a mouthwash containing alcohol
Correct answer: C
Rationale: The correct answer is to instruct the client to use a soft toothbrush. Using a soft toothbrush helps prevent bleeding in clients receiving chemotherapy, who are at risk for mucositis. Encouraging the client to eat high-protein foods (Choice A) is important for overall health but not directly related to preventing infection. Encouraging the client to drink 2 liters of fluid daily (Choice B) is essential for hydration but does not specifically prevent infection. Instructing the client to use a mouthwash containing alcohol (Choice D) is contraindicated as alcohol-containing mouthwashes can cause irritation and dryness in the oral mucosa, increasing the risk of infection.
4. What is the most important intervention for a client with delirium?
- A. Administer sedative medication
- B. Identify any reversible causes of delirium
- C. Provide a low-stimulation environment
- D. Increase environmental stimulation
Correct answer: B
Rationale: The correct answer is to identify any reversible causes of delirium. Delirium can be caused by various factors such as infections, medications, or metabolic imbalances. Addressing these underlying causes can help resolve delirium. Administering sedative medication (Choice A) can worsen delirium by further altering mental status. Providing a low-stimulation environment (Choice C) is helpful to manage delirium symptoms, but it is not the most important intervention. Increasing environmental stimulation (Choice D) is contraindicated in delirium as it can exacerbate confusion and agitation.
5. A client with hypothyroidism may present with which of the following findings?
- A. Weight gain
- B. Hair loss
- C. Dry skin
- D. Diarrhea
Correct answer: C
Rationale: Dry skin is a common manifestation of hypothyroidism due to decreased thyroid hormone levels, leading to reduced sweating and oil production. Weight gain may occur due to a slowed metabolism, not diarrhea, as hypothyroidism is more commonly associated with constipation. Hair loss is typically associated with hyperthyroidism, not hypothyroidism.
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