6574627-Silvestri501-600 - PN~Comp~Review~CD~501-600~ 1 PN...

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PN~Comp~Review~CD~501-600~ PN Comprehensive Review CD Questions 501-600 {COMP: No Equations/Formulas; No <AQ> questions} 501. A nurse finds a client lying tense in bed and staring at the cardiac monitor. The client states, “There sure are a lot of wires around there. I sure hope we don’t get hit by lightning!” The appropriate nursing response would be: 1. “Would you like a mild sedative to help you relax?” 2. “Oh, don’t worry; the weather is supposed to be sunny and clear today!” 3. “Yes, all those wires must be a little scary. Did someone explain what the cardiac monitor was for?” 4. “Your family can stay tonight if they wish.” Answer: 3 Rationale: The nurse should initially respond to validate the client’s concern and then should determine the client’s knowledge level of the cardiac monitor. This gives the nurse an opportunity to perform client education if necessary. Bringing in the family, friends, or a chaplain as an alternate resource may provide the client with additional psychological support. Pharmacological interventions should be considered only if necessary. Option 2 is a communication block. Test-Taking Strategy: Use the process of elimination. Because the client is the first priority, the focus of the nurse’s concern should be the client’s feelings, preferences, and choices. Option 3 validates the client’s anxiety and goes a step further to determine why the client might be anxious. Remember, address the client’s feelings first. Review therapeutic communication techniques if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Communication and Documentation Content Area: Adult Health/Cardiovascular Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 437. 502. A maternity nurse inspects the amniotic fluid from a client following an amniotomy. The nurse documents that the amniotic fluid is normal if which of the following is noted? 1. It is light green with no odor 2. It is thick and white with no odor 3. It is clear and dark amber 4. It is pale with flecks of vernix Answer: 4 1
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PN~Comp~Review~CD~501-600~ Rationale: Amniotic fluid is normally pale and straw-colored and may contain flecks of vernix caseosa. It should have a watery, not thick, consistency and no odor. Amber fluid suggests the presence of bilirubin, whereas greenish fluid may indicate the presence of meconium and suggests fetal distress. Test-Taking Strategy: Focus on the issue—that the amniotic fluid is normal. Noting the words “flecks of vernix” in option 4 will direct you to this option. Review this content if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Intrapartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 108.
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  • Spring '16
  • content area, cognitive ability, W. B. Saunders

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