Nokea
A client with preeclampsia is admitted with an order for magnesium sulfate. Which action by the nurse indicates an understanding of magnesium toxicity?
- A. The nurse lowers the temperature of the room.
- B. The nurse places an airway at the bedside.
- C. The nurse inserts an indwelling catheter and obtains an hourly intake and output.
- D. The nurse darkens the room to reduce environmental stimuli.
Correct Answer: B
Rationale: Magnesium sulfate toxicity can cause respiratory depression or arrest. Placing an airway at the bedside prepares for potential emergency intervention. The other actions are less specific to managing magnesium toxicity.
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The client is diagnosed with a urinary tract infection. Which instruction should the nurse include in the discharge teaching?
- A. Limit fluid intake to reduce bladder irritation.'
- B. Take all prescribed antibiotics as directed.'
- C. Avoid sexual activity permanently.'
- D. Use heating pads to relieve discomfort.'
Correct Answer: B
Rationale: Completing the full course of antibiotics is essential to eradicate the infection and prevent resistance in a urinary tract infection. Fluid intake should increase, sexual activity can resume after treatment, and heating pads may not be advised.
A female client is started on warfarin (Coumadin) 5 mg po bid. To adequately evaluate the effectiveness of the warfarin therapy, the nurse must know that this medication:
- A. Dissolves any clots already formed in the arteries
- B. Prevents the conversion of prothrombin to thrombin
- C. Interferes with the synthesis of vitamin K-dependent clotting factors
- D. Stimulates the manufacturing of platelets
Correct Answer: C
Rationale: Thrombolytic agents (e.g., streptokinase) directly activate plasminogen, dissolving fibrin deposits, which in turn dissolves clots that have already formed. Heparin prevents the formation of clots by potentiating the effects of antithrombin III and the conversion of prothrombin to thrombin. Warfarin prevents the formation of clots by interfering with the hepatic synthesis of the vitamin K-dependent clotting factors. Platelets initiate the coagulation of blood by adhering to each other and the site of injury to form platelet plugs.
The nurse is caring for a client with suspected endometrial cancer.
- A. Frothy vaginal discharge
- B. Thick, white vaginal discharge
- C. Purulent vaginal discharge
- D. Watery vaginal discharge
Correct Answer: D
Rationale: Endometrial cancer often presents with abnormal uterine bleeding, which can manifest as watery vaginal discharge. Frothy discharge is more typical of trichomoniasis, thick white discharge suggests a yeast infection, and purulent discharge indicates infection, none of which are primary symptoms of endometrial cancer.
The nurse is assessing a client with suspected anaphylactic shock. Which intervention is the priority?
- A. Administer epinephrine
- B. Start an IV fluid bolus
- C. Place the client in Trendelenburg position
- D. Administer oxygen via nasal cannula
Correct Answer: A
Rationale: Epinephrine is the priority in anaphylactic shock to reverse bronchoconstriction and hypotension. IV fluids and oxygen are secondary, and Trendelenburg is not recommended.
Which finding in the patient's history contraindicates the use of Imitrex (sumatriptan) for the prevention of migraine headaches?
- A. Diabetes
- B. Angina
- C. Renal calculi
- D. Peptic ulcer disease
Correct Answer: B
Rationale: Sumatriptan (Imitrex) is a vasoconstrictor contraindicated in patients with angina due to the risk of coronary artery vasoconstriction and ischemia. Diabetes renal calculi and peptic ulcer disease are not contraindications for sumatriptan.