The adolescent patient reports to the clinic nurse that her period is late, but that her home pregnancy test is negative. What should the nurse explain that these findings most likely indicate?
1. "This means you are not pregnant.".
2. "You might be pregnant, but it might be too early for your home test to be accurate.".
3. "We don't trust home tests. Come to the clinic for a blood test.".
4. "Most people don't use the tests correctly. Did you read the instructions?"
2
Rationale 1: Although it might be true that she is not pregnant, this is not the best statement, because the pregnancy might be too early for a urine pregnancy test to detect.
Rationale 2: This is a true statement. Most home pregnancy tests have low false-positive rates, but the false-negative rate is slightly higher. Repeating the test in a week is recommended.
Rationale 3: This statement is not therapeutically worded. A clinic pregnancy test is usually a urine test.
Rationale 4: Although this statement gets at the need to read the instructions for the test, it is not therapeutically worded.
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The nurse notes that when a neonate is stroked on the left cheek, he turns his head toward the left. The nurse is assessing a(n):
a. normal reflex called the tonic neck reflex. b. abnormal response that needs to be further evaluated. c. abnormal response known as head turning. d. normal reflex called the rooting reflex.
The nurse gives an example of a person who is attempting to maintain homeostasis as the newcomer who:
1. joins a local church. 2. buys a new car. 3. stays in his or her apartment watching TV. 4. spends hours writing e-mail to old friends.
What is the best technique for the nurse to use to ensure that an air embolus does not develop when changing the administration set on a central venous catheter?
A. Place the client in a flat, right side–lying position during the procedure. B. Have the client in a semisitting position to ensure that the catheter exit site is above the level of the heart. C. Have the client hold his or her breath and bear down while the old set is discon-nected and the new set is connected. D. Cap off the old set and remove it, attach a 10-mL syringe with sterile normal sa-line to the connector, then rapidly attach the new primed set to the catheter con-nection.
A registered nurse (RN) who has a licensed practical nurse (LPN) and a nursing assistant on the nursing team is planning client assignments for the day. Which of the following clients should the RN assign to the LPN?
A. A client on bedrest who needs assistance with feeding B. A client who must be turned and repositioned every 2 hours C. A client receiving oxygen who requires frequent pulse oximetry monitoring and respiratory treatments D. A client with retinal detachment who is wearing eye patches and requires assistance with hygiene measures