Nokea
A client 6 weeks postpartum is asking the nurse about taking progesterone (Depo-Provera) for birth control. Which of the following should the nurse determine? Select all that apply.
- A. If the client has a sexually transmitted disease.
- B. How willing her husband is to have her take the drug.
- C. If the woman is experiencing postpartum depression.
- D. That the woman is not currently pregnant.
- E. If the woman is breast-feeding.
Correct Answer: C,D,E
Rationale: The nurse should assess for postpartum depression, pregnancy status, and breast-feeding, as these affect Depo-Provera's safety and efficacy. STDs and husband's willingness are not primary concerns.
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A child with a diagnosis of sickle cell disease is admitted to the hospital for treatment of vaso-occlusive pain crisis. The nurse should plan for which interventions in the care of the client? Select all that apply.
- A. Increase fluid intake.
- B. Administer oxygen.
- C. Administer meperidine.
- D. Perform frequent pain assessment.
- E. Administer intravenous (IV) fluids.
Correct Answer: A,B,D,E
Rationale: Management of the severe pain that occurs with vaso-occlusive crisis includes frequent pain assessment and the use of strong opioid analgesics, such as morphine sulfate and hydromorphone. Fluids are necessary to promote hydration, so options related to the delivery of fluids are appropriate. Oxygen is administered to increase tissue perfusion. Meperidine is contraindicated because of its side effects and increased risk of seizures after as few as 2 doses.
A client who has a history of chronic ulcerative colitis is diagnosed with anemia. The nurse interprets that which factor is most likely responsible for the anemia?
- A. Blood loss
- B. Intestinal hookworm
- C. Intestinal malabsorption
- D. Decreased intake of dietary iron
Correct Answer: A
Rationale: The client with chronic ulcerative colitis is most likely anemic as a result of chronic blood loss in small amounts that occurs with exacerbations of the disease. These clients often have bloody stools and are at increased risk for anemia. There is no information in the question to support options 2 or 4. In ulcerative colitis, the large intestine is involved, not the small intestine, where vitamin B12 and folic acid are absorbed.
A client is receiving a continuous infusion of heparin. The nurse notes a partial thromboplastin time (PTT) of 120 seconds. What should the nurse do first?
- A. Stop the infusion
- B. Reduce the infusion rate
- C. Administer protamine sulfate
- D. Notify the physician
Correct Answer: A
Rationale: A PTT of 120 seconds is significantly above the therapeutic range (1.5 to 2 times normal), indicating a risk of bleeding. Stopping the infusion is the first action to prevent harm.
A 30-year-old client is hospitalized with a fractured femur, which is being treated with skeletal traction. He states that he has not had a bowel movement for 2 days. Which of the following interventions is most appropriate at this time?
- A. Administer a tap water enema.
- B. Place the client on the bedpan every 2 to 3 hours.
- C. Increase the client's fluid intake to 3,000 mL/day.
- D. Perform range-of-motion movements to all extremities.
Correct Answer: C
Rationale: Increasing fluid intake promotes bowel motility, addressing constipation in a client immobilized by traction.
The nurse is beginning the shift and is now responsible for the following clients on the postpartum unit and has not yet made rounds on the clients. Additionally, the nurse is responsible for three other clients who are currently listed as stable. The nurse will also be getting a new admission in 15 minutes. For the best utilization of time and client safety, the nurse should make rounds on which of the following clients first?
- A. The three clients who are reported to be stable.
- B. The mother with a 4-hour-old infant with initial blood glucose of 33 mg\dL and now at 15 mg/dL.
- C. A mother who had a spontaneous vaginal delivery (SVD) client and received methylergonovine maleate (Methergine) 1 hour ago for increased bleeding.
- D. A mother with a 3-day-old who had a bilirubin level of 13 mg\dL 30 minutes ago, and is now in a 'bili blanket' at the mother's bedside.
Correct Answer: B
Rationale: The infant with a blood glucose of $15 \mathrm{mg} / \mathrm{dL}$ is critically low, indicating severe hypoglycemia, which requires immediate intervention to prevent neurological damage.