Nokea
A client at 6 months' gestation complains of tiredness and dizziness. Her hemoglobin level is 10 g/dL, and her hematocrit value is 32%. Her nutritional intake is assessed as sufficient. The most likely diagnosis is:
- A. Iron-deficiency anemia
- B. Physiological anemia
- C. Fatigue due to stress
- D. No problem indicated
Correct Answer: A
Rationale: This clinical situation is indicative of iron-deficiency anemia because the client has inadequate nutritional intake. Her blood volume is increasing faster than her red blood cell volume. Anemia is present in the second trimester when the hemoglobin level is <10.5 and the hematocrit value falls below 35%. She needs increased iron supplements with follow-up. The client's values are below levels for physiological anemia. The client is fatigued because of a low hemoglobin level. Her hemoglobin level is low and will probably decrease even more when the blood volume peaks at 28 weeks.
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A 45-year-old male client was admitted to a chemical dependency treatment center following legal problems related to alcohol abuse. He states, 'I know that alcohol is a problem for some people, but I can stop whenever I want to. I'm never sick or miss work, and no one can complain about me.' During the initial assessment, the best response by the nurse would be:
- A. The fact is you are an alcoholic or you wouldn't be here.
- B. I understand it took strength to admit yourself to the unit, and I will do my part to help you to stay alcohol-free.
- C. If you can stop drinking when you want to, why don't you stop?
- D. It's good that you can stop drinking when you want to.
Correct Answer: B
Rationale: Direct confrontation initially is nontherapeutic and may result in the client becoming frustrated and wanting to leave. A positive, supportive attitude builds trust, and identifying positive strength raises self-esteem. Offering help allows the client to feel that he is not alone in dealing with problems. Asking the client why or to give an explanation for his behavior puts him in a position of having to justify his behavior to the nurse. Giving approval or placing a value on feelings or a behavior may limit the client's freedom to behave in a way that may displease another. This response may lead to seeking praise instead of progress.
The client is admitted with a diagnosis of preterm premature rupture of membranes (PPROM). The nurse should prepare to administer which medication?
- A. Magnesium sulfate
- B. Terbutaline
- C. Betamethasone
- D. All of the above
Correct Answer: C
Rationale: Betamethasone is administered in PPROM (24-34 weeks) to enhance fetal lung maturity in anticipation of preterm delivery. Magnesium sulfate may be used for neuroprotection or preeclampsia and terbutaline is a tocolytic but betamethasone is the priority.
A client is admitted to the hospital for an induction of labor owing to a gestation of 42 weeks confirmed by dates and ultrasound. When she is dilated 3 cm, she has a contraction of 70 seconds. She is receiving oxytocin. The nurse's first intervention should be to:
- A. Check FHT
- B. Notify the attending physician
- C. Turn off the IV oxytocin
- D. Prepare for the delivery because the client is probably in transition
Correct Answer: C
Rationale: FHT should be monitored continuously with an induction of labor; this is an accepted standard of care. The physician should be notified, but this is not the first intervention the nurse should do. The standard of care for an induction according to the Association of Women's Health, Obstetric, and Neonatal Nurses and American College of Obstetrics and Gynecology is that contractions should not exceed 60 seconds in an induction. Inductions should simulate normal labor; 70-second contractions during the latent phase (3 cm) are not the norm. The next contractions can be longer and increase risks to the mother and fetus. Contractions lasting 60-90 seconds during transition are typical; this provides a good distractor. The nurse needs to be knowledgeable of the phases and stages of labor.
The nurse is caring for a client with a history of a myocardial infarction. The client is receiving TPA (alteplase). The nurse should monitor the client for:
- A. Bleeding
- B. Hypertension
- C. Hypoglycemia
- D. Hyperthermia
Correct Answer: A
Rationale: TPA, a thrombolytic, increases bleeding risk by dissolving clots. Monitoring for bleeding (e.g., gums, urine) is critical. Hypertension, hypoglycemia, and hyperthermia are not primary concerns.
The nurse is caring for a client with a history of a fractured femur who is in a cast. The client complains of swelling. The nurse should:
- A. Apply ice to the cast
- B. Elevate the leg
- C. Massage the leg
- D. Notify the physician immediately
Correct Answer: B
Rationale: Elevating the leg reduces swelling in a casted femur by improving venous return. Ice is helpful, massage is contraindicated, and notification is needed if swelling persists.