A client is seen in the emergency department in shock. X-rays reveal protrusion of a portion of the fetus through the maternal abdomen. The nurse hypothesizes that the client has experienced which of the following?
a. Placenta previa c. Abruptio placentae
b. Uterine rupture d. Umbilical cord pro-lapse
B
Uterine rupture involves a separation of the uterine wall that may allow protrusion of fetal parts into the maternal abdomen. A longitudinal rupture, sometimes referred to as a classic rupture, occurs over the body of the uterus and is an acute emergent situation.
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A client had a vaginoplasty under epidural anesthetic. Which action by the nurse is most important?
a. Ensure that the urinary catheter is securely attached to the leg. b. Instruct the client not to try to get out of bed unassisted. c. Monitor the client's dressings and wound drainage. d. Position the Jackson-Pratt drain to the contralateral side.
At the scene of a terrorist attack, the nurse assists with triaging victims. Which victim should be seen as first priority or most urgent? (Select all that apply.)
a. Victim is pulseless. b. Victim has chest pain. c. Victim has multiple fractures. d. Victim has chest wound. e. Victim has a head injury with loss of consciousness. f. Victim has third-degree burns.
Which country is a patient from Hispanic origin most likely to be from in the United States?
A. Mexico B. Cuba C. Puerto Rico D. The Dominican Republic
Which statement related to delegation is correct?
a. The practice of unlicensed assistive personnel (UAP) is defined in the nurse practice act. b. Nursing practice can be delegated only when the LPN/LVN and/or UAP have received adequate training. c. Supervision is not required when routine tasks are delegated to a competent individual. d. The RN must be knowledgeable about the laws and regulations that govern nursing practice, as well as those that have no clearly defined parameters, such as for UAP.