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NEW QUESTION 22
The nurse begins morning assessment on a male client and notices that she is unable to palpate either of his dorsalis pedis pulses in his feet. What is the first nursing action after assessing this finding?
- A. Document the finding that the pulses are not palpable.
- B. Call the physician and notify the physician of this finding.
- C. Use a Doppler to determine presence and strength of these pulses.
- D. Palpate these pulses again in 15 minutes.
Section: Questions Set D
(A) Palpating these pulses again in 15 minutes may only result in the same findings. (B) Any time during an assessment that the nurse is unable to palpate pulses, the nurse should then obtain a Doppler and assess for presence or absence of the pulse and pulse strength, if a pulse is present. (C) Pulses may be present and assessed through use of a Doppler. Absence of palpable pulses does not indicate absence of blood flow unless pulses cannot be located with a Doppler. (D) The nurse would only call the physician after determining that the pulses are absent by both palpation and Doppler.
NEW QUESTION 23
A 20-year-old female client delivers a stillborn infant. Following the delivery, an appropriate response by the labor nurse to the question, “Why did this happen to my baby?” is:
- A. “I can see you’re upset. Would you like to see and hold your baby?”
- B. “It’s God’s will. It was probably for the best. There was something probably wrong with your baby.”
- C. “You’re young. You can have other children later.”
- D. “I know your other children will be a great comfort to you.”
(A) The mother and the father require support; the nurse should not minimize their grief in this situation. (B) Attachment to this infant occurs during the pregnancy for both the mother and father. Another child cannot replace this child. (C) Attachment to this infant occurs during the pregnancy for both the mother and father.
Siblings will not replace their feelings or minimize their loss of this infant. (D) Holding and viewing the infant decreases denial and may facilitate the grief process. The nurse should prepare family members for how the infant appears (“she is bruised”) and provide support.
NEW QUESTION 24
When preparing insulin for IV administration, the nurse identifies which kind of insulin to use?
- A. NPH
- B. Long acting
- C. Regular
- D. Human or pork
(A, B, D) Intermediate-acting and long-acting preparations contain materials that increase length of absorption time from the subcutaneous tissues but cause the preparation to be cloudy and unsuitable for IV use. Human insulin must be given SC. (C) Only regular insulin can be given IV.
NEW QUESTION 25
Which of the following activities would be most appropriate during occupational therapy for a client with bipolar disorder?
- A. Playing cards with other clients
- B. Sewing beads on a leather belt
- C. Working crossword puzzles
- D. Playing tennis with a staff member
Section: Questions Set A
(A) This activity is too competitive, and the manic client might become abusive toward the other clients. (B) During mania, the client’s attention span is too short to accomplish this task. (C) This activity uses gross motor skills, eases tension, and expands excess energy. A staff member is better equipped to interact therapeutically with clients. (D) This activity requires the use of fine motor skills and is very tedious.
NEW QUESTION 26
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