Nokea
A client with hypertension and type 2 diabetes has recently started taking chlorthalidone. Which report by the client is most concerning to the nurse?
- A. Dizziness on standing
- B. Fasting blood glucose of 180 mg/dL (10.0 mmol/L)
- C. Presence of muscle cramps
- D. Sunburn on both arms
Correct Answer: A
Rationale: Dizziness on standing suggests orthostatic hypotension, a serious side effect of chlorthalidone, which can lead to falls. Elevated glucose and muscle cramps are concerning but less urgent, and sunburn is unrelated.
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A client is waiting to have an intravenous pyelogram (IVP). The most important information to be obtained by the nurse prior to the procedure is
- A. time of the client's last meal
- B. client's allergy history
- C. assessment of the peripheral pulses
- D. results of the blood coagulation studies
Correct Answer: B
Rationale: Intravenous Pyelogram is a dye study that uses an iodine-based contrast. Therefore, the study is contraindicated in clients with allergy to iodine.
The nurse is caring for a newborn 12 hours after an uncomplicated vaginal birth at 39 weeks gestation. Which of the following findings would require follow up? Select all that apply.
- A. Plantar creases are present over the entire soles of the feet
- B. Skin on the forehead blanches to a yellowish hue
- C. Toes fan outward as the sole of the foot is stroked upward
- D. Umbilical cord has one artery and one vein
- E. White, pearl-like cysts are present on the gum margins
Correct Answer: B,D
Rationale: Yellowish skin suggests jaundice, which requires monitoring for bilirubin levels. An umbilical cord with one artery (instead of two) and one vein may indicate congenital anomalies, needing further evaluation. Plantar creases are normal at 39 weeks, the Babinski reflex (toes fanning) is expected, and gum cysts (Epstein pearls) are benign.
The nurse is assessing a 16-year-old mother for potential child abuse. Which factor is most important when assessing the potential for child abuse?
- A. Age of the mother
- B. Marital status
- C. Socioeconomic status
- D. Abuse as a child
Correct Answer: D
Rationale: A history of being abused as a child is the strongest predictor of potential child abuse, as it influences parenting behaviors.
The nurse is preparing 7:00 AM medications for a client with a urinary tract infection and a history of heart failure and type 2 diabetes. Based on the information from the medical and medication records, which prescription should the nurse question before administering?
- A. Furosemide
- B. Glipizide
- C. Levofloxacin
- D. Potassium chloride
Correct Answer: A
Rationale: Furosemide in heart failure requires careful monitoring of fluid status and electrolytes, especially early in the day, to avoid exacerbating dehydration or hypotension. Glipizide, levofloxacin, and potassium chloride are appropriate for diabetes, UTI, and potential hypokalemia, respectively.
The nurse is caring for a client from the Middle East. The nurse is aware that the client will most likely:
- A. Want to take time for prayer during the day.
- B. Ask for specially prepared foods.
- C. Refuse blood products.
- D. Want to be treated by a medicine man.
Correct Answer: A
Rationale: Many Middle Eastern clients prioritize daily prayer, a cultural practice that nurses should accommodate.