Nokea
A client elects to have epidural anesthesia to relieve the discomfort of labor. Following the initiation of epidural anesthesia, the nurse should give priority to:
- A. Checking for cervical dilation
- B. Placing the client in a supine position
- C. Checking the client's blood pressure
- D. Obtaining a fetal heart rate
Correct Answer: C
Rationale: Epidural anesthesia can cause hypotension, making blood pressure monitoring a priority.
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The client delivered a 9-pound infant two days ago. An effective means of managing discomfort from an episiotomy is:
- A. Medicated suppository
- B. Taking showers
- C. Sitz baths
- D. Ice packs
Correct Answer: C
Rationale: Sitz baths relieve episiotomy pain by promoting circulation and healing.
The doctor has prescribed Cortone (cortisone) for a client with systemic lupus erythematosis. Which instruction should be given to the client?
- A. Take the medication 30 minutes before eating.
- B. Report changes in appetite and weight.
- C. Wear sunglasses to prevent cataracts.
- D. Schedule a time to take the influenza vaccine.
Correct Answer: B
Rationale: Cortisone can cause weight gain and appetite changes, which should be monitored in SLE to manage side effects.
If the nurse is providing education to a male client who is HIV positive, which of the following information should the nurse include? Select all that apply.
- A. Need to use condoms for every sexual encounter.
- B. Need to tell sexual or needle-sharing partners about HIV status.
- C. Signs and symptoms indicating increased viral load and infections.
- D. Importance of maintaining a healthy lifestyle.
- E. Availability of support groups.
Correct Answer: A,B,C,D,E
Rationale: HIV education includes condoms (A), disclosing status (B), monitoring symptoms (C), healthy lifestyle (D), and support groups (E) to manage disease and prevent transmission.
A client has been receiving cyanocobalamine (B12) injections for the past six weeks. Which laboratory finding indicates that the medication is having the desired effect?
- A. Neutrophil count of 60%
- B. Basophil count of 0.5%
- C. Monocyte count of 2%
- D. Reticulocyte count of 1%
Correct Answer: D
Rationale: Increased reticulocyte count indicates effective B12 therapy for anemia.
The nurse gives a 35-year-old primigravida client a RhoGAM injection in her 27th week of pregnancy. Which of the following client situations requires the nurse to take this action?
- A. Rh-negative mother and Rh-positive father
- B. Rh-negative mother and Rh-negative father
- C. Rh-positive mother and Rh-negative father
- D. Rh-positive mother and Rh-positive father
Correct Answer: A
Rationale: RhoGAM is given to an Rh-negative mother with an Rh-positive father to prevent Rh incompatibility issues in the fetus.