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NO.552 At 38 weeks' gestation, a client is in active labor. She is using her Lamaze
breathing techniques. The RN is coaching her breathing and encouraging her to relax
and work with her contractions. Which one of the following complaints by the client
will alert the RN that she is beginning to hyperventilate with her breathing?
A. "I am cold."
B. "I have a backache."
C. "I feel dizzy."
D. "I am
nauseous."
Answer: C
Explanation:
(A)
Cold is not a symptom of hyperventilation. This could be due to the temperature of the
room. (B) Backache is not a symptom of hyperventilation. This is probably due to the
gravid uterus
,and its effect on the back muscles, or it may be due to the client's
position in bed. (C)
Dizziness is the first symptom of hyperventilation. It occurs because the body is
eliminating too much CO2. (D) Nausea is not a symptom of hyperventilation. It could be
a symptom of pain.
NO.553 At 16 weeks' gestation, a pregnant client is admitted to the maternity unit to
have a McDonald procedure (cerclage) done. She tells the RN who is admitting her to
the unit that her physician had explained what this procedure was, but that she did
not understand. The RN explains to the client that the purpose for this procedure is
to:
A. Reinforce an incompetent cervix
B. Repair the amniotic sac
C. Evaluate cephalopelvic disproportion
D. Dilate the
cervix Answer:
A Explanation:
(A) The treatment most commonly uses the Shirodkar-Barter procedure (McDonald
procedure) or cerclage to enforce the weakened cervix by encircling it with a suture
at the level of the internal os.
(B) There is no known procedure that is used to repair the amniotic sac. (C)
Cephalopelvic disproportion is evaluated later in pregnancy. It is not related to this
procedure. (D) No procedure is done to dilate the cervix at 16 weeks' gestation
unless the pregnancy is to be terminated.
NO.554 While the nurse is taking a male client's blood pressure, he makes
flirtatious remarks to her. The nurse will handle this effectively if she:
A. Politely tells the client, "Keep your hands off "
B. Ignores the remarks and hopes he will not try it again
, C. Confronts the remarks but attempts not to reject the client
D. Leaves the room in order to compose herself
Answer: C
Explanatio
n:
(A)
This response does not recognize normal feelings of attraction and
rejects the client. (B)
By ignoring the situation, the nurse has not set limits to discourage other remarks or
perhaps more sexually aggressive behavior. (C) By confronting the remarks, she can
recognize that his feelings of attraction may be normal but are not appropriate
within the context of their nurse-client relationship. (D) Leaving the room does not
deal with setting limits for future interactions.
NO.555 A 74-year-old obese man who has undergone open reduction and internal
fixation of the right hip is 8 days postoperative. He has a history of arthritis and atrial
fibrillation. He admits to right lower leg pain, described as "a cramp in my leg." An
appropriate nursing action is to:
A. Assess for pain with plantiflexion
B. Assess for edema and heat of the right leg
C. Instruct him to rub the cramp out of his leg