Nokea
A client with hypertension and type 2 diabetes has recently started taking chlorthalidone. Which report by the client is most concerning to the nurse?
- A. Dizziness on standing
- B. Fasting blood glucose of 180 mg/dL (10.0 mmol/L)
- C. Presence of muscle cramps
- D. Sunburn on both arms
Correct Answer: A
Rationale: Dizziness on standing suggests orthostatic hypotension, a serious side effect of chlorthalidone, which can lead to falls. Elevated glucose and muscle cramps are concerning but less urgent, and sunburn is unrelated.
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The nurse is reinforcing teaching to a client, gravida 1 para 0, at 8 weeks gestation about expected weight gain during pregnancy. The client's prepregnancy BMI is 21 kg/m?. Which statement made by the client indicates an appropriate understanding about weight gain?
- A. I should gain 10-15 pounds during the first trimester.
- B. I should gain about 30 pounds during the entire pregnancy!
- C. I should gain no more than half a pound per week during the third trimester
- D. If I gain less than 20 pounds during pregnancy, it will be easier to lose weight postpartum
Correct Answer: B
Rationale: Appropriate weight gain during pregnancy decreases risks to the client and fetus. Optimal weight gain is determined by prepregnancy BMI. Underweight clients need to gain more weight (~1 lb [0.5 kg] per week) during the second and third trimesters of pregnancy than obese clients (~0.5 lb [0.2 kg] per week). However, weight gain in the first trimester should be 1.1-4.4 lb (0.5-2.0 kg), regardless of BMI.
A couple from the Philippines living in the United States is expecting their first child. In providing culturally competent care, the nurse must first:
- A. review their own cultural beliefs and biases.
- B. respectfully request that the couple utilize only medically approved health care providers.
- C. realize that the clients have to learn their new country's accepted medical practices.
- D. study family dynamics to understand the male and female gender roles in the clients' culture.
Correct Answer: A
Rationale: Self-awareness of the nurse's own cultural biases is the first step in providing culturally competent care, ensuring nonjudgmental interactions. The other actions are secondary or prescriptive. Psychosocial Integrity
The nurse working on the renal unit is preparing to make rounds for the day. Which client should the nurse visit first?
- A. The client maintained on hemodialysis
- B. The client with chronic glomerulonephritis
- C. The client one hour post-renal transplant
- D. The client scheduled for an IVP
Correct Answer: C
Rationale: The client one hour post-renal transplant is at highest risk for complications, such as bleeding or graft rejection, requiring immediate assessment. Other clients are stable or less urgent.
The nurse is caring for a newborn 12 hours after an uncomplicated vaginal birth at 39 weeks gestation. Which of the following findings would require follow up? Select all that apply.
- A. Plantar creases are present over the entire soles of the feet
- B. Skin on the forehead blanches to a yellowish hue
- C. Toes fan outward as the sole of the foot is stroked upward
- D. Umbilical cord has one artery and one vein
- E. White, pearl-like cysts are present on the gum margins
Correct Answer: B,D
Rationale: Yellowish skin suggests jaundice, which requires monitoring for bilirubin levels. An umbilical cord with one artery (instead of two) and one vein may indicate congenital anomalies, needing further evaluation. Plantar creases are normal at 39 weeks, the Babinski reflex (toes fanning) is expected, and gum cysts (Epstein pearls) are benign.
A 4 year-old child is recovering from chicken pox (varicella). The parents would like to have the child return to day care as soon as possible. In order to ensure that the illness is no longer communicable, what should the nurse assess for in this child?
- A. All lesions crusted
- B. Elevated temperature
- C. Rhinorrhea and coryza
- D. Presence of vesicles
Correct Answer: A
Rationale: All lesions crusted. The child is no longer contagious when all lesions are crusted over.