Nokea
A nurse is assessing a client who has preeclampsia and is receiving magnesium sulfate via continuous IV infusion. For which of the following therapeutic effects should the nurse monitor the client?
- A. Deep tendon reflexes 2+
- B. Pulse rate 100/min
- C. Urine output 20 mL/hr
- D. 1+ proteinuria via urine dipstick
Correct Answer: A
Rationale: The correct answer is A: Deep tendon reflexes 2+. Monitoring deep tendon reflexes is crucial when a client is receiving magnesium sulfate due to its potential to cause muscle weakness and CNS depression. The nurse should assess for hyperreflexia, which indicates magnesium toxicity. Choices B, C, and D are incorrect as they do not directly relate to the therapeutic effect of magnesium sulfate. Pulse rate and urine output may be affected by the medication but are not specific therapeutic effects to monitor for. Proteinuria can be a sign of kidney damage but is not a direct effect of magnesium sulfate therapy.
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A nurse is teaching a client who has a new diagnosis of diabetes mellitus about foot care. Which of the following instructions should the nurse include in the teaching?
- A. Soak feet twice daily.
- B. Round the edges of toenails when trimming.
- C. Use moisturizing lotion between the toes.
- D. Wear clean cotton socks every day.
Correct Answer: D
Rationale: The correct answer is D: Wear clean cotton socks every day. This instruction is essential for proper foot care in diabetes mellitus as it helps prevent fungal infections and keeps feet dry. Soaking feet twice daily (choice A) can lead to skin breakdown. Rounding the edges of toenails (choice B) can increase the risk of ingrown toenails. Using moisturizing lotion between the toes (choice C) can create a moist environment, fostering fungal growth. Therefore, wearing clean cotton socks daily is the most appropriate instruction to promote foot health in a client with diabetes mellitus.
A nurse is reinforcing teaching about advance directives with a client who has end-stage renal disease. Which of the following client statements indicates an understanding of the teaching?
- A. I know that I can change my advance directives if needed in the future.
- B. My healthcare proxy will make decisions as soon as I sign the power of attorney.
- C. My family can overrule the decisions made by my healthcare proxy.
- D. Advance directives from one state are valid in any other state.
Correct Answer: A
Rationale: Rationale: Option A is correct because it shows the client understands that advance directives can be modified. This is crucial as preferences may change over time. Option B is incorrect as the healthcare proxy only makes decisions when the client cannot. Option C is incorrect as the healthcare proxy's decisions are legally binding. Option D is incorrect because advance directives must comply with state laws and may not be universally recognized.
A nurse is caring for a client who asks for information regarding organ donation. Which of the following responses should the nurse make?
- A. I cannot be a witness for your consent to donate.
- B. You must be at least 21 years of age to become an organ donor.
- C. Your desire to be an organ donor must be documented in writing.
- D. Your name cannot be removed once you are listed on the organ donor list.
Correct Answer: C
Rationale: The correct response is C: Your desire to be an organ donor must be documented in writing. This is the correct answer because in order for someone to become an organ donor, their wish to donate organs after death must be formally documented. This ensures that their wishes are legally binding and will be respected. It also helps healthcare providers and family members honor the individual's decision.
Other choices are incorrect because:
A: This response does not provide the necessary information about organ donation.
B: Age requirements for organ donation may vary by country or region, but it is not a universal rule.
D: Individuals can opt-out of being an organ donor at any time, so this statement is false.
E, F, G: No information given, so it is unclear if these choices are relevant to organ donation.
A nurse is caring for a client who has pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate?
- A. Contact
- B. Droplet
- C. Airborne
- D. Protective
Correct Answer: B
Rationale: The correct answer is B: Droplet precautions. Pharyngeal diphtheria is primarily spread through respiratory droplets when an infected person coughs or sneezes. Droplet precautions involve wearing a mask and eye protection within 3 feet of the patient to prevent the transmission of respiratory secretions. Contact precautions (Choice A) are for diseases transmitted through direct contact with the patient or contaminated surfaces. Airborne precautions (Choice C) are for diseases spread through tiny particles that can remain suspended in the air for long periods. Protective precautions (Choice D) are not a standard precaution type.
A nurse is conducting health promotion education regarding contraindications to combination oral contraceptive use to a group of women. Which of the following conditions should the nurse include in the teaching?
- A. Hypertension
- B. Fibromyalgia
- C. Renal calculi
- D. Fibrocystic breast disease.
Correct Answer: A
Rationale: The correct answer is A: Hypertension. Hypertension is a contraindication to combination oral contraceptive use due to the increased risk of cardiovascular events. The estrogen component in oral contraceptives can further elevate blood pressure, leading to complications. Other choices like B: Fibromyalgia, C: Renal calculi, and D: Fibrocystic breast disease are not contraindications for oral contraceptive use. Fibromyalgia is a chronic pain condition unrelated to oral contraceptives. Renal calculi are kidney stones, which do not directly affect the safety of oral contraceptives. Fibrocystic breast disease is a benign condition and not a contraindication to oral contraceptives.