Nokea
A client with a history of phenylketonuria (PKU) is seen in the local family planning clinic. While completing the intake history, the nurse provides information for a healthy pregnancy. Which statement indicates that the client needs further teaching?
- A. I can use artificial sweeteners to keep me from gaining too much weight when I get pregnant.
- B. I need to go back on a low-phenylalanine diet before I get pregnant.
- C. Fresh fruits and raw vegetables will make good between-meal snacks for me.
- D. My baby could be mentally retarded if I don't stick to a diet eliminating phenylalanine.
Correct Answer: A
Rationale: Artificial sweeteners like aspartame contain phenylalanine, which is harmful in PKU. A low-phenylalanine diet, healthy snacks, and preventing mental retardation are correct understandings.
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The nurse assesses a postoperative mastectomy client and notes the breath sounds are diminished in both posterior bases. The nurse's action should be to:
- A. Encourage coughing and deep breathing each hour
- B. Obtain arterial blood gases
- C. Increase O2 from 2-3 L/min
- D. Remove the postoperative dressing to check for bleeding
Correct Answer: A
Rationale: Decreased or absent breath sounds are frequently indicators of postoperative atelectasis. Arterial blood gases are not indicated because there is no other information indicating impending danger. Increasing O2 rate is not indicated without additional information. Removing the dressing is not indicated without additional information.
The nurse is teaching the client regarding use of sodium warfarin. Which statement made by the client would require further teaching?
- A. I will have blood drawn every month.'
- B. I will assess my skin for a rash.'
- C. I take aspirin for a headache.'
- D. I will use an electric razor to shave.'
Correct Answer: C
Rationale: Taking aspirin while on warfarin increases bleeding risk due to their combined anticoagulant effects. The client needs further teaching to avoid aspirin. Monthly blood draws (for INR), checking for rashes (a side effect), and using an electric razor (to reduce cuts) are appropriate.
The client is admitted with a diagnosis of abruptio placenta. Which vital sign change is most likely to be observed?
- A. Tachycardia
- B. Hypotension
- C. Fetal bradycardia
- D. All of the above
Correct Answer: D
Rationale: Abruptio placenta causes maternal tachycardia and hypotension (from bleeding) and fetal bradycardia (from hypoxia). All vital sign changes are likely in this condition.
A client had a transurethral resection of the prostate yesterday. He is concerned about the small amount of blood that is still in his urine. The nurse explains that the blood in his urine:
- A. Should not be there on the second day
- B. Will stop when the Foley catheter is removed
- C. Is normal and he need not be concerned about it
- D. Can be removed by irrigating the bladder
Correct Answer: C
Rationale: Some hematuria is usual for several days after surgery. The client should not be concerned about it unless it increases.
A client with a history of chronic venous insufficiency is admitted with complaints of leg ulcers. The nurse should give priority to:
- A. Wound care
- B. Administering pain medication
- C. Monitoring blood pressure
- D. Administering diuretics
Correct Answer: A
Rationale: Wound care is critical for leg ulcers in chronic venous insufficiency to promote healing and prevent infection.