Nokea
A client with a history of chronic kidney disease 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 diuretics
Correct Answer: A
Rationale: Fatigue in chronic kidney disease often results from anemia due to low erythropoietin, so monitoring for anemia is the priority.
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The client is admitted with a diagnosis of gestational diabetes. Which fetal monitoring technique is most appropriate?
- A. Non-stress test
- B. Biophysical profile
- C. Both A and B
- D. Neither A nor B
Correct Answer: C
Rationale: Gestational diabetes increases fetal risks (e.g. macrosomia hypoglycemia) requiring close monitoring. Non-stress tests assess fetal heart rate and biophysical profiles evaluate fetal well-being comprehensively. Both are appropriate.
Prenatal clients are routinely monitored for early signs of pregnancy-induced hypertension (PIH). For the prenatal client, which of the following blood pressure changes from baseline would be most significant for the nurse to report as indicative of PIH?
- A. 136/88 to 144/93
- B. 132/78 to 124/76
- C. 114/70 to 140/88
- D. 140/90 to 148/98
Correct Answer: C
Rationale: PIH is indicated by a systolic increase of 30 mm Hg or diastolic increase of 15 mm Hg; 114/70 to 140/88 shows a 26 mm Hg systolic and 18 mm Hg diastolic change, most significant for PIH.
The nurse is teaching a client with a history of hypertension about medication adherence. The nurse should tell the client to:
- A. Take antihypertensives as prescribed
- B. Skip doses if feeling better
- C. Increase sodium intake
- D. Avoid exercise
Correct Answer: A
Rationale: Adherence to antihypertensives is critical in hypertension to maintain blood pressure control and prevent complications.
Which of the following nursing care goals has the highest priority for a child with epiglottitis?
- A. Sleep or lie quietly 10 hr/day.
- B. Consume foods from all four food groups.
- C. Be afebrile throughout her hospital stay.
- D. Participate in play activities 4 hr/day.
Correct Answer: A
Rationale: Of these four goals, maintenance of a calm, quiet atmosphere to reduce anxiety and to allow for rest is the most important. Although nutrition is important, the child needs fluids to maintain fluid and electrolyte balance more than solid foods. In addition, the child may not be able to swallow solid foods owing to epiglottic swelling. This goal is unrealistic because fever is a common symptom of the infection associated with epiglottitis. If overexerted, the child will need more O2 and energy than available, and these requirements may exacerbate the condition.
The nurse is caring for a client with a history of cirrhosis. The nurse should give priority to:
- A. Monitoring for bleeding
- B. Administering diuretics
- C. Monitoring blood glucose
- D. Assessing for infection
Correct Answer: A
Rationale: Cirrhosis impairs clotting factor production, increasing bleeding risk, so monitoring for bleeding is a priority.