Nokea
A client develops a temperature of 102°F following coronary artery bypass surgery. The nurse should notify the physician immediately because elevations in temperature:
- A. Increase cardiac output
- B. Indicate cardiac tamponade
- C. Decrease cardiac output
- D. Indicate graft rejection
Correct Answer: C
Rationale: Fever post-CABG increases metabolic demand, potentially decreasing cardiac output in a compromised heart, requiring immediate attention. Tamponade and rejection have other signs.
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A client with a renal failure is prescribed a low potassium diet. Which food choice would be best for this client?
- A. 1 cup beef broth
- B. 1 baked potato with the skin
- C. 1/2 cup raisins
- D. 1 cup rice
Correct Answer: D
Rationale: A low potassium diet is essential for clients with renal failure to prevent hyperkalemia. Among the options, 1 cup of rice has the lowest potassium content (approximately 50–100 mg per cup), making it the best choice. Beef broth contains moderate potassium (around 200 mg per cup), a baked potato with skin is high in potassium (about 900 mg), and raisins are also high (around 500 mg per half cup).
The client is admitted with a diagnosis of chorioamnionitis. Which symptom is most likely to be present?
- A. Maternal fever
- B. Fetal macrosomia
- C. Decreased uterine contractions
- D. Maternal hypotension
Correct Answer: A
Rationale: Chorioamnionitis an infection of the amniotic fluid and membranes typically causes maternal fever. Fetal macrosomia decreased contractions and hypotension are not primary symptoms.
The client is admitted with a diagnosis of postpartum endometritis. Which symptom is most likely to be present?
- A. Foul-smelling lochia
- B. Painless vaginal bleeding
- C. Decreased uterine tenderness
- D. Fetal distress
Correct Answer: A
Rationale: Postpartum endometritis a uterine infection typically causes foul-smelling lochia due to bacterial infection. Painful uterine tenderness is common painless bleeding suggests other causes and fetal distress is irrelevant postpartum.
A client is 6 weeks pregnant. During her first prenatal visit, she asks, 'How much alcohol is safe to drink during pregnancy?' The nurse's response is:
- A. Up to 1 oz daily
- B. Up to 2 oz daily
- C. Up to 4 oz weekly
- D. No alcohol
Correct Answer: D
Rationale: No amount of alcohol has been determined safe for pregnant women. Alcohol should be avoided owing to the risk of fetal alcohol syndrome. The recommended safe dosage of alcohol consumption during pregnancy is none.
Which of the following is an adverse effect associated with the use of Adriamycin (doxorubicin)?
- A. Ventricular arrhythmias
- B. Alopecia
- C. Leukopenia
- D. Stomatitis
Correct Answer: B
Rationale: Alopecia (hair loss) is a common adverse effect of doxorubicin, a chemotherapeutic agent, due to its impact on rapidly dividing cells, including hair follicles.