Nokea
A client with preeclampsia has been receiving an infusion containing magnesium sulfate for a blood pressure that is 160/80; deep tendon reflexes are 1 plus, and the urinary output for the past hour is 100 mL. The nurse should:
- A. Continue the infusion of magnesium sulfate while monitoring the client's blood pressure
- B. Stop the infusion of magnesium sulfate and contact the physician
- C. Slow the infusion rate and turn the client on her left side
- D. Administer calcium gluconate IV push and continue to monitor the blood pressure
Correct Answer: A
Rationale: The parameters (BP 160/80, 1+ reflexes, 100 mL urine output) are within acceptable limits, so the infusion should continue.
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The nurse is providing discharge teaching for a client taking dissulfiram (Antabuse). The nurse should instruct the client to avoid eating:
- A. Peanuts, dates, raisins
- B. Figs, chocolate, eggplant
- C. Pickles, salad with vinaigrette dressing, beef
- D. Milk, cottage cheese, ice cream
Correct Answer: C
Rationale: Vinaigrette may contain alcohol, which reacts with disulfiram, causing severe symptoms.
The nurse is providing instruction to a client's family regarding home safety with thrombocytopenia. Which statement by the client's family indicates a need for further education?
- A. He should use an electric razor for shaving instead of a razor.
- B. We will use soft-bristled toothbrushes or tooth sponges for oral care.
- C. He can no longer take aspirin or aspirin-containing products for a headache.
- D. We should put rugs down on the hardwood floors to prevent his feet from getting cold.
Correct Answer: D
Rationale: Rugs pose a tripping hazard, increasing bleeding risk in thrombocytopenia. Other statements reflect safe practices to minimize bleeding.
Upon admission to the hospital, a client reports having 'the worst headache I've ever had.' The nurse should give the highest priority to:
- A. Administering pain medication
- B. Starting oxygen
- C. Performing neuro checks
- D. Inserting a Foley catheter
Correct Answer: C
Rationale: A sudden, severe headache may indicate a serious condition like subarachnoid hemorrhage. Neuro checks are the priority to assess for neurological changes.
A client who is Muslim is refusing to eat food served to him by a nursing assistant. The nurse should do which of the following? Select all that apply.
- A. arrange a mealtime that will avoid prayer times
- B. remove farm-raised catfish from the food tray
- C. arrange with the family for halal food to be brought from home
- D. deliver food by a nursing assistant of the same sex
Correct Answer: A, C
Rationale: Arranging mealtimes to avoid prayer times and providing halal food respects the client's religious dietary practices. The gender of the assistant and specific foods like catfish are less relevant unless explicitly non-halal.
The nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate (TURP). The nurse notes that the urine output is bright red with clots. Which of the following actions should the nurse take FIRST?
- A. Increase the irrigation flow rate.
- B. Notify the physician.
- C. Administer a diuretic as ordered.
- D. Stop the irrigation and assess the catheter.
Correct Answer: B
Rationale: bright red urine with clots indicates potential bleeding, requiring immediate physician notification