A patient at 28 weeks' gestation is being assessed for preterm labor. Which finding indicates that preterm labor is occurring?
A) Ferning is found in the vaginal secretions
B) Irregular mild contractions are occurring every 10 to 15 minutes
C) Fetal fibronectin is present in vaginal secretions
D) The cervix is effacing and dilated to 2 cm
Ans: C
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An elderly patient is admitted to your unit with a diagnosis of community-acquired pneumonia. During admission the patient states, "I have a living will." What implication of this should the nurse recognize?
A) This document is always honored, regardless of circumstances. B) This document specifies the patient's wishes before hospitalization. C) This document that is binding for the duration of the patient's life. D) This document has been drawn up by the patient's family to determine DNR status.
A patient with a large inguinal hernia has abdominal distention and inguinal pain. The nurse recognizes these as indicators of which type of hernia?
a. Strangulated b. Hiatal c. Ventral d. Umbilical
The nurse is conducting a physical assessment for a client with a compromised immune system. Which actions by the nurse are appropriate?
Select all that apply. A) Assessing general appearance B) Recommending increased fluid intake C) Inspecting the mucous membranes of the nose and mouth for color and condition D) Palpating the cervical lymph nodes for evidence of lymphadenopathy or tenderness E) Checking joint range of motion (ROM), including that of the spine
A patient complains of a lesion in his nose. Which technique does a nurse use to inspect the nasal mucosa?
a. Inserts a nasal speculum horizontally into the patient's affected nares b. Inserts a nasal speculum obliquely into the patient's affected nares c. Uses a light source from the ophthalmoscope d. Inserts a nasal speculum vertically into the patient's affected nares