Nokea
A 23-year-old woman at 32-weeks gestation is seen in the outpatient clinic. Which of the following findings, if assessed by the nurse, would indicate a possible complication?
- A. The client’s urine test is positive for glucose and acetone.
- B. The client has 1+ pedal edema in both feet at the end of the day.
- C. The client complains of an increase in vaginal discharge.
- D. The client says she feels pressure against her diaphragm when the baby moves.
Correct Answer: A
Rationale: abnormal finding, could indicate gestational diabetes (GDM), hazard of placental insufficiency
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The nurse has performed discharge teaching to a client in need of a high-iron diet. The nurse recognizes that teaching has been effective when the client selects which meal plan?
- A. Hamburger, French fries, and orange juice
- B. Sliced veal, spinach salad, and whole-wheat roll
- C. Vegetable lasagna, Caesar salad, and toast
- D. Bacon, lettuce, and tomato sandwich; potato chips; and tea
Correct Answer: B
Rationale: Veal and spinach are high in iron, and whole-wheat roll provides additional nutrients. The other meals lack significant iron sources.
The physician prescribes regular insulin, 5 units subcutaneous. Regular insulin begins to exert an effect:
- A. In 5-10 minutes
- B. In 10-20 minutes
- C. In 30-60 minutes
- D. In 60-120 minutes
Correct Answer: C
Rationale: Regular insulin has an onset of 30-60 minutes when given subcutaneously.
The nurse is making assignments for the day. The staff consists of an RN, a novice RN, an LPN, and a nursing assistant. Which client should be assigned to the RN?
- A. A client with peptic ulcer disease
- B. A client with skeletal traction for a fractured femur
- C. A client with an abdominal cholecystectomy
- D. A client with an esophageal tamponade
Correct Answer: D
Rationale: The client with an esophageal tamponade requires complex monitoring and intervention, best suited for an experienced RN.
A client is being discharged on Coumadin after hospitalization for a deep vein thrombosis. The nurse recognizes that which food would be restricted while the client is on this medication?
- A. Lettuce
- B. Apples
- C. Potatoes
- D. Macaroni
Correct Answer: A
Rationale: Lettuce, especially leafy greens, is high in vitamin K, which can antagonize Coumadin's anticoagulant effect, requiring dietary restriction or monitoring.
The nurse is caring for a client diagnosed with glaucoma. The health care provider has ordered timolol maleate. Which finding in the client's history would prompt the nurse to notify the health care provider?
- A. asthma
- B. migraines
- C. atrial fibrillation
- D. urinary tract infection
Correct Answer: A
Rationale: Timolol, a beta-blocker, can exacerbate asthma by causing bronchoconstriction. Other conditions are not contraindications.