Nokea
A 24-year-old nulligravid client with a history of irregular menstrual cycles visits the clinic because she suspects that she is 'about 6 weeks pregnant.' An ultrasound is scheduled in 2 weeks. The nurse should instruct the client that this test will be done to:
- A. Assess gestational age.
- B. Determine a multifetal pregnancy.
- C. Identify the gender of the fetus.
- D. Assess of maternal pelvic adequacy.
Correct Answer: A
Rationale: An early ultrasound at around 8 weeks is primarily used to confirm gestational age and viability.
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Buspirone hydrochloride is prescribed for a client diagnosed with an anxiety disorder. The nurse providing instructions should inform the client about which characteristic of this medication?
- A. There is risk of addiction.
- B. Dizziness and nausea may occur.
- C. Tolerance can occur with the medication.
- D. The medication can produce a sedating effect.
Correct Answer: B
Rationale: Buspirone hydrochloride is used in the management of anxiety disorders. The medication has a more favorable side effect profile than do the benzodiazepines. Dizziness, nausea, headaches, lightheadedness, and paradoxical central nervous system excitement, which generally are not major problems, are side effects of the medication. The advantages of this medication are that it is not addicting, tolerance does not develop, and it is not sedating.
The nurse coordinates with the laboratory staff to have the gentamicin trough serum level drawn. At what time should the blood be drawn in relation to the administration of the I.V. dose of gentamicin sulfate [Garamycin]?
- A. 2 hours before the administration of the next I.V. dose.
- B. 3 hours before the administration of the next I.V. dose.
- C. 4 hours before the administration of the next I.V. dose.
- D. Just before the administration of the next I.V. dose.
Correct Answer: D
Rationale: The trough level, which measures the lowest drug concentration, is drawn just before the next dose to ensure the drug is within a therapeutic range and to avoid toxicity.
A client diagnosed with active tuberculosis (TB) is to be admitted to a medical-surgical unit. Which action should the nurse take when planning a bed assignment?
- A. Place the client in a private, well-ventilated room.
- B. Plan to transfer the client to the intensive care unit.
- C. Reserve the bed furthest away from the door in a double room.
- D. Assign the client to share a double room with a noninfectious client.
Correct Answer: A
Rationale: According to category-specific (respiratory) isolation precautions, a client with TB requires a private room. The room needs to be well ventilated and should have at least 6 to 12 exchanges of fresh air per hour and should be ventilated to the outside if possible. Therefore, option 1 is the only correct choice.
Which of the following terms is used to describe the sound, timely, smooth, unfragmented and seamless transition of the client from one level of acuity to another?
- A. Case management
- B. Continuity of care
- C. Medical necessity
- D. Critical pathway
Correct Answer: B
Rationale: Continuity of care refers to the seamless, coordinated transition of a client across different levels of care, ensuring consistent and effective treatment.
The nurse is assessing a client with a suspected bowel obstruction. Which of the following findings is most indicative of this condition?
- A. Abdominal distension.
- B. Decreased bowel sounds.
- C. Soft, nontender abdomen.
- D. Frequent loose stools.
Correct Answer: A,B
Rationale: Abdominal distension and decreased bowel sounds are hallmark signs of bowel obstruction due to blocked intestinal passage.