Nokea
A nulligravid client with gestational diabetes tells the nurse that she had a reactive nonstress test 3 days ago and asks, 'What does that mean?' The nurse explains that a reactive nonstress test indicates which of the following about the fetus?
- A. Evidence of some compromise that will require delivery soon.
- B. Fetal well-being at this point in the pregnancy.
- C. Evidence of late decelerations occurring during the test.
- D. No accelerations demonstrated within a 20-minute period.
Correct Answer: B
Rationale: A reactive nonstress test, showing fetal heart rate accelerations, indicates fetal well-being.
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After several months of taking olanzapine (Zyprexa), the client reports that he is no longer hearing voices of any kind. Which of the following would confirm that the client is developing insight into his illness?
- A. That Zyprexa is the best medicine I have ever had.'
- B. I didn't realize how sick I could get from a chemical brain imbalance.'
- C. My mom is proud of me for staying on my medicines.'
- D. I think I may be able to get a little part-time job soon.'
Correct Answer: B
Rationale: Acknowledging a chemical brain imbalance shows insight into the biological basis of the illness, indicating understanding of the need for treatment.
A postpartum client is experiencing heavy lochia 3 days after delivery. Which action should the nurse take first?
- A. Massage the fundus
- B. Administer oxytocin as ordered
- C. Encourage the client to ambulate
- D. Notify the physician
Correct Answer: A
Rationale: Heavy lochia may indicate uterine atony. Massaging the fundus is the first step to promote uterine contraction and reduce bleeding before escalating to other interventions.
A nulliparous client visiting the clinic tells the nurse that she stopped taking oral contraceptives 6 months ago but doesn't think she is ovulating. Which of the following should the nurse anticipate that the physician would order if the client is anovulatory?
- A. Denestrol (Ortho Dienestrol)
- B. Clomiphene citrate (Clomid)
- C. Medroxyprogesterone (Depo-Provera)
- D. Norgestrel (Ovrette)
Correct Answer: B
Rationale: Clomiphene citrate is commonly prescribed to stimulate ovulation in anovulatory clients. Denestrol is an estrogen, medroxyprogesterone is a progestin for contraception or other uses, and norgestrel is a contraceptive, not for inducing ovulation.
A client being discharged from the hospital with a diagnosis of gastric ulcer has a prescription for sucralfate 1 gram by mouth 4 times daily. The nurse determines that the client understands proper use of the medication when the client states the intention to take the medication at which time?
- A. With meals and at bedtime
- B. Every 6 hours around the clock
- C. One hour after meals and at bedtime
- D. One hour before meals and at bedtime
Correct Answer: D
Rationale: Sucralfate is an antiulcer medication. The medication should be scheduled for administration 1 hour before meals and at bedtime. This timing will allow the medication to form a protective coating over the ulcer before it becomes irritated by food intake, gastric acid production, and mechanical movement. The other options are incorrect.
The nurse is caring for a client with a history of burns. Which of the following nutritional interventions should be included in the plan of care?
- A. High-protein, high-calorie diet.
- B. Low-sodium diet.
- C. Low-fat diet.
- D. High-fiber diet.
Correct Answer: A
Rationale: A high-protein, high-calorie diet supports tissue repair and energy needs in burn recovery.