The client with Cushing’s disease has adrenocortical hypersecretion. This increase in the level of cortisone causes the client to be immunosuppressed. Option B: the client with diabetes poses no risk to other clients. Option C: The client has an increase in growth hormone and poses no risk to himself or others. Option D: The client has hypothyroidism or myxedema and poses no risk to others or himself.
An amniotomy is an artificial rupture of membranes and normal amniotic fluid is straw-colored and odorless. Options A and C: Fetal heart tones of 160 indicate tachycardia, and greenish fluid is indicative of meconium. Option D: If the nurse notes the umbilical cord, the client is experiencing a prolapsed cord and would need to be reported immediately.
Remember the ABCs (airway, breathing, circulation) when answering this question. Before notifying the physician or assessing the pulse, oxygen should be applied to increase the oxygen saturation, so answers A and D are incorrect. The normal oxygen saturation for a child is 92%–100%, making answer B incorrect.
The pregnant nurse should not be assigned to any client with radioactivity present. The client receiving linear accelerator therapy travels to the radium department for therapy. The radiation stays in the department, so the client is not radioactive. These clients are radioactive in very small doses, especially upon returning from the procedures. For approximately 72 hours, the clients should dispose of urine and feces in special containers and use plastic spoons and forks. Options B, C, and D: The following clients pose a risk to the pregnant nurse.
Infection with pinworms begins when the eggs are ingested or inhaled. The eggs hatch in the upper intestine and mature in 2–8 weeks. The females then mate and migrate out the anus, where they lay up to 17,000 eggs. This causes intense itching. The mother should be told to use a flashlight to examine the rectal area about 2–3 hours after the child is asleep. Placing clear tape on a tongue blade will allow the eggs to adhere to the tape. The specimen should then be brought in to be evaluated. Options B, C, and D: There is no need to scrape the skin, collect a stool specimen, or bring a sample of hair.
It is normal for the client to have a warm sensation when dye is injected. Options A, C, and D indicate that the nurse believes that the hot feeling is abnormal, so they are incorrect.
Applying a fetal heart monitor is the correct action at this time. Options A and C: There is no need to prepare for a Caesarean section or to place the client in Genupectoral position (knee-chest). Option D: There is no need for an ultrasound based on the finding.
When the client is taking oral contraceptives and begins antibiotics, another method of birth control should be used. Antibiotics decrease the effectiveness of oral contraceptives. Option A: Approximately 5–10 pounds of weight gain is not unusual. Option C: If the client misses a birth control pill, she should be instructed to take the pill as soon as she remembers the pill. If she misses two, she should take two; if she misses more than two, she should take the missed pills but use another method of birth control for the remainder of the cycle. Option D: Changes in menstrual flow are expected in clients using oral contraceptives. Often these clients have lighter menses.
Epidural anesthesia decreases the urge to void and sensation of a full bladder. A full bladder will decrease the progression of labor. Answers A, B, and D are incorrect for the stem.
Please select 3 correct answers
Please select 2 correct answers
It can scrutinize only uncomplicated phenomena.
Credibility is the truth of findings as judged by the participants (A). Auditability assists the reader to judge the appropriateness of the interview questions posed (B). Auditability assists the reader to judge the adequacy of the coding system used (D).
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NCLEX-RN Test #9
