A nurse is caring for a client who has an abruptio placentae. Which of the following findings should the nurse expect?

First trimester bleeding

Severe abdominal pain

Nausea

Delayed menses

Answer and Explanation

The Correct Answer is B

A. First trimester bleeding. Abruptio placentae typically occurs in the third trimester, not the first. First trimester bleeding is more commonly associated with miscarriage or ectopic pregnancy.
B. Severe abdominal pain. Abruptio placentae involves the premature separation of the placenta from the uterine wall, often leading to sudden, severe abdominal pain and possibly vaginal bleeding. It is a medical emergency requiring immediate attention.
C. Nausea. While nausea can occur during pregnancy, it is not a hallmark symptom of abruptio placentae and does not assist in differentiating it from other complications.
D. Delayed menses. Delayed menses may indicate early pregnancy, but it is not related to abruptio placentae, which occurs later in pregnancy.

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Correct Answer is C,B,A,D

Explanation

C. Lubricate the catheter with sterile saline. After donning sterile gloves, the nurse should lubricate the catheter to reduce friction and prevent trauma to the tracheal mucosa during insertion.

B. Insert the catheter until resistance is felt. The catheter should be gently inserted into the tracheostomy until resistance is met, indicating that it has reached the carina. Inserting beyond this point may cause injury.

A. Withdraw the catheter 1 to 2 cm (0.4 to 0.8 in). Pulling back slightly after resistance ensures the catheter is not pressing directly on sensitive structures and is positioned correctly for effective suctioning.

D. Rotate the catheter while suctioning. Suction should be applied while withdrawing the catheter in a rotating motion to evenly clear secretions and minimize damage to the tracheal lining.

A. A client who consumes all the food from their meal tray. B. A client who has a prescription for compression stockings and did not receive them. C. A client who requests to sit in the bedside chair while watching TV. D. A client who requests assistance to use the bedside commode.

Correct Answer is B

Explanation

A. A client who consumes all the food from their meal tray. This is a normal finding and does not require immediate reporting to the nurse. It can be documented by the AP as part of routine care.
B. A client who has a prescription for compression stockings and did not receive them. Compression stockings are a prescribed intervention to prevent complications such as deep vein thrombosis. The nurse must be informed to ensure timely application and follow-up.
C. A client who requests to sit in the bedside chair while watching TV. This is a non-urgent and appropriate activity that does not require nursing intervention unless the client has specific mobility restrictions.
D. A client who requests assistance to use the bedside commode. Assisting with toileting is within the AP’s scope of practice and does not need to be reported unless there is an issue (e.g., change in condition, abnormal findings).

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A nurse is caring for a client who has an abruptio placentae. Which of the following findings should the nurse expect?

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Naxlex Comprehensive Predictor Exams

11. A nurse is caring for a client who has a tracheostomy and requires suctioning. Identify the sequence of steps the nurse should follow after applying sterile gloves. (Move the steps into the box, placing them in the selected order of performance. Use all the steps.)

Correct Answer is C,B,A,D

Explanation

A nurse and an assistive personnel (AP) are assigned a group of clients on the unit. Which of the following clients should the nurse instruct the AP to report to the nurse?

Correct Answer is B

Explanation

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