Nokea
A client with a history of breast cancer is admitted with complaints of fatigue. The nurse should give priority to:
- A. Monitoring for anemia
- B. Administering pain medication
- C. Monitoring blood pressure
- D. Administering chemotherapy
Correct Answer: A
Rationale: Fatigue in breast cancer may indicate anemia, a common complication, so monitoring for anemia is the priority.
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A newborn weighing 7 pounds at birth should be expected to weigh pounds by one year of age.
Correct Answer: 21 pounds
Rationale: Newborns typically triple their birth weight by one year. 7 lbs × 3 = 21 lbs.
A client with a history of phenylketonuria is seen at the local family planning clinic. After completing the client's intake history, the nurse provides literature for a healthy pregnancy. Which statement indicates that the client needs further teaching?
- A. I can help control my weight by switching from sugar to Nutrasweet.
- B. I need to resume my old diet before becoming pregnant.
- C. I need to eliminate most sources of phenylalanine from my diet.
- D. Fresh fruits and raw vegetables will make excellent between-meal snacks.
Correct Answer: A
Rationale: Nutrasweet (aspartame) contains phenylalanine, which is harmful in phenylketonuria, so this statement indicates a need for further teaching.
The nurse is teaching a client with a history of kidney stones about dietary modifications. The nurse should tell the client to:
- A. Increase fluid intake
- B. Avoid all calcium
- C. Consume high-oxalate foods
- D. Reduce protein intake
Correct Answer: A
Rationale: Increasing fluid intake dilutes urine, reducing the risk of kidney stone formation.
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.
The nurse is caring for a client with a history of a pneumothorax who has a chest tube in place. The nurse should:
- A. Clamp the chest tube during transport
- B. Strip the chest tube every hour
- C. Keep the drainage system below chest level
- D. Empty the drainage system daily
Correct Answer: C
Rationale: Keeping the drainage system below chest level prevents fluid backflow into the chest. Clamping risks pneumothorax, stripping is outdated, and emptying is per protocol, not daily.