1.) During her first trimester, a woman experiences many physiological changes that lead her to think she is pregnant. Which of the following changes will the nurse most likely tell her are normal for an eight-week pregnancy?
1.Dysuria
2.Colostrum secretion
3.Nosebleeds
4.Dependent edema
Answer no. 3
Rationale:
Epistaxis (nosebleed) occurs in the first trimester. It is related to capillary dilation.
2.) Which of the following nursing interventions indicate an understanding on the part of the nurse concerning proper care of pressure ulcers?
1.Rub reddened skin to increase circulation.
2.Use a heat lamp four times a day to dry the wound surface.
3.Cleanse a noninfected pressure ulcer with isotonic saline.
4.Cleanse a noninfected pressure ulcer with povodone-iodine.
Answer no. 3
Rationale:
A noninfected pressure ulcer should be cleansed gently with a nonionic cleanser such as isotonic saline to prevent disruption of healing.
3.) An adult is hospitalized for treatment of deep electrical burns. Burn wound sepsis develops and mafenide acetate 10% (Sulfamylon) is ordered bid. While applying the Sulfamylon to the wound, it is important for the nurse to prepare the client for expected responses to the topical application, which include
1.Severe burning pain for a few minutes following application.
2.Possible severe metabolic alkalosis with continued use.
3.Black discoloration of everything that comes in contact with this drug.
4.Chilling due to evaporation of solution from the moistened dressings.
Answer no.1
Rationale:
Mafenide acetate 10% (Sulfamylon) does cause burning on application. An analgesic may be required before the ointment is applied.
4.) A client who is 25 weeks pregnant with no previous medical or obstetrical problems is admitted to the hospital in premature labor. The nurse can expect that orders for this client, in addition to bed rest, will include which of the following?
1.A fetal monitor and a tocolytic.
2.A fetal monitor and a tranquilizer.
3.A maternal cardiac monitor and fluid therapy.
4.A fetal monitor and a maternal cardiac monitor.
Answer no. 1
Rationale:
Monitoring fetal heart rate assesses fetal well-being and fetal distress. A tocolytic is administered to relax the smooth muscles of the uterus and inhibit uterine contractility.
5.) A co nstruction worker complains of low back pain that increases when he bends over, coughs, or lifts objects. A diagnosis of herniated disc is made. He asks the nurse to explain the cause of his pain. The nurse’s response is based on knowledge that pain associated with a herniated disc results from
1.Compression of the spinal nerve root.
2.Spasms of the paraspinal muscles.
3.A friction rub created by degeneration of vertebrae.
4.Edema and swelling of nerve endings.
Answer no. 1
Rationale:
The intervertebral disc is a cartilaginous plate that forms a cushion between the vertebral plates. In herniation of the disc, the nucleus of the disc protrudes into the annulus (the fibrous ring around the disc) with subsequent compression of the spinal nerve as it emerges from the spinal column. This causes pain in the area of nerve distribution.
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