Nokea
A client has a cerclage placed at 16 weeks' gestation. She has had no contractions and her cervix is dilated 2 cm. The nurse is preparing the client for discharge. Which statement by the client should indicate to the nurse that the client needs further instruction?
- A. I will need more frequent prenatal visits.'
- B. I should call if I am leaking fluid or have bleeding or contractions.'
- C. I can have sex again in about 2 weeks.'
- D. I can have nothing in my vagina until I am at term.'
Correct Answer: C
Rationale: Sexual intercourse is typically contraindicated after cerclage until term to prevent complications. The other statements reflect correct understanding of cerclage care.
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A client with a diagnosis of gastroesophageal reflux disease (GERD) has just received a breakfast tray. The nurse notices that which is the only food that will increase the lower esophageal sphincter (LES) pressure and thus lessen the client's symptoms?
- A. Coffee
- B. Nonfat milk
- C. Fresh scrambled eggs
- D. Whole wheat toast with butter
Correct Answer: B
Rationale: Foods that increase the LES pressure will decrease reflux and lessen the symptoms of GERD. The food substance that will increase the LES pressure is nonfat milk. The other substances listed decrease the LES pressure, thus increasing reflux symptoms. Aggravating substances include chocolate, coffee, fatty foods, and alcohol and should be avoided in the diet of a client with GERD.
Which of the following is a nursing diagnosis that reflects some unexpected response to a therapy?
- A. Episiotomy extension related to a forceps delivery
- B. Respiratory depression related to NSAIDs
- C. Hemothorax related to a latex allergy
- D. All of the above
Correct Answer: D
Rationale: All listed diagnoses reflect unexpected responses to therapies (forceps delivery, NSAIDs, latex exposure), qualifying as adverse reactions.
Which instruction should the nurse provide to the client prescribed the medication benztropine mesylate?
- A. Sit in the sun for 30 minutes daily.
- B. Avoid driving if drowsiness or dizziness occurs.
- C. Expect difficulty swallowing while taking this medication.
- D. Expect episodes of vomiting and constipation while taking this medication.
Correct Answer: B
Rationale: The client taking benztropine mesylate, anti-Parkinson's agent and anticholinergic agent, should be instructed to avoid driving or operating hazardous equipment if drowsy or dizzy. The client's tolerance to heat may be reduced because of the diminished ability to sweat, and the client should be instructed to plan rest periods in cool places during the day. The client should be instructed to contact the primary health care provider immediately if difficulty swallowing or speaking or vomiting occurs. The client should also inform the primary health care provider if central nervous system effects occur. The client is instructed to monitor urinary output and watch for signs of constipation.
The nurse is caring for a client with a history of atrial fibrillation who is prescribed amiodarone (Cordarone). Which of the following side effects should the nurse monitor for?
- A. Pulmonary toxicity.
- B. Hyperglycemia.
- C. Weight gain.
- D. Hair loss.
Correct Answer: A
Rationale: Amiodarone can cause pulmonary toxicity, a serious side effect requiring regular monitoring of lung function.
The nurse provides discharge instructions to a client after implantation of a permanent pacemaker. The nurse should instruct the client to avoid exposure to which item?
- A. Hair dryers
- B. Electric blankets
- C. Electric toothbrushes
- D. Airport metal detectors
Correct Answer: D
Rationale: A pacemaker is shielded from interference from most electrical devices. Devices to be forewarned about include those with a strong electric current or magnetic field, such as antitheft devices in stores, metal detectors used in airports, and radiation therapy (if applicable and which might require relocation of the pacemaker). Radios, televisions, electric blankets, toasters, microwave ovens, heating pads, and hair dryers are considered to be safe.