Nokea
The nurse is caring for a client at 15 weeks gestation who has hyperemesis gravidarum. Which of the following findings would be consistent with the condition?
- A. heart rate less than 60/min
- B. moderate to high urine ketones
- C. increased serum potassium level
- D. blood pressure greater than 140/90 mm Hg
Correct Answer: B
Rationale: Hyperemesis gravidarum causes severe vomiting, leading to ketosis (moderate to high urine ketones) from fat breakdown. Bradycardia, hyperkalemia, and hypertension are not typical; tachycardia and hypokalemia may occur.
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The nurse is reinforcing teaching for a client with atrial fibrillation who has a new prescription for warfarin. The nurse should instruct the client to avoid excess or inconsistent intake of which of the following foods? Select all that apply.
- A. red meat
- B. bananas
- C. broccoli
- D. spinach
- E. kale
Correct Answer: C,D,E
Rationale: Broccoli, spinach, and kale are high in vitamin K, which can antagonize warfarin's anticoagulant effect. Consistent intake is key, but excess can reduce effectiveness. Red meat and bananas have minimal vitamin K and don't significantly affect warfarin.
A staff nurse complains to the nurse manager that an unlicensed assistive personnel (UAP) consistently leaves the work area untidy and does not restock supplies. The best initial response by the nurse manager is which of these statements?
- A. I will arrange for a conference with you and the UAP within the next week
- B. I can assure you that I will look into the matter
- C. I would like for you to approach the UAP about the problem the next time it occurs
- D. I will add this concern to the agenda for the next unit meeting
Correct Answer: C
Rationale: Helping staff manage conflict is part of the manager's role. It is appropriate to urge the nurse to confront the other staff member to work out problems without a manager's intervention when possible.
The nurse is providing home care for an immobile client who has a stage IV decubitus ulcer that is not healing. Assuming that all of the following are available, which person would be most appropriate to consult regarding care of the wound?
- A. Physician
- B. Physical therapist
- C. IV therapist
- D. Enterostomal therapist
Correct Answer: D
Rationale: An enterostomal therapist specializes in wound and ostomy care, making them the most appropriate consultant for managing a non-healing stage IV decubitus ulcer. Physicians oversee care, physical therapists focus on mobility, and IV therapists manage infusions.
The nurse is observing a 3-year-old client for expected developmental milestones. It would require follow-up if the client cannot
- A. catch a ball at least 50% of the time
- B. copy a square with a pencil or crayon
- C. eat with a spoon
- D. hop on one foot
Correct Answer: B
Rationale: Copying a square is expected by age 4-5, not 3, indicating a fine motor delay requiring follow-up. Catching a ball, eating with a spoon, and hopping are age-appropriate or slightly advanced for a 3-year-old.
When teaching a client about the side effects of fluoxetine (Prozac), which of the following will the nurse include?
- A. Tachycardia, blurred vision, hypotension, anorexia
- B. Orthostatic hypotension, vertigo, reactions to tyramine-rich foods
- C. Diarrhea, dry mouth, weight loss, reduced libido
- D. Photosensitivity, seizures, edema, hyperglycemia
Correct Answer: C
Rationale: Diarrhea, dry mouth, weight loss, reduced libido. Commonly reported side effects for fluoxetine (Prozac) are diarrhea, dry mouth, weight loss and reduced libido.