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A nurse is caring for a client who has severe preeclampsia. Which of the following interventions should the nurse include in the plan of care?
- A. Administer magnesium sulfate.
- B. Place the client in the left lateral position.
- C. Monitor intake and output.
- D. Provide a low-sodium diet.
Correct Answer: C
Rationale: The correct intervention for a client with severe preeclampsia is to monitor intake and output. This is crucial to assess kidney function, fluid balance, and detect any signs of deterioration. Administering magnesium sulfate is indicated for seizure prophylaxis in severe preeclampsia, but it is not the primary intervention related to care planning. Placing the client in the left lateral position is not a specific intervention for managing preeclampsia. Providing a low-sodium diet is not typically recommended for clients with severe preeclampsia as sodium restriction is not a primary treatment modality for this condition.
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A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate intravenously. The nurse discontinues the magnesium sulfate after the client displays toxicity. Which of the following actions should the nurse take?
- A. Position the client supine.
- B. Prepare an IV bolus of dextrose 5% in water.
- C. Administer methylergonovine IM.
- D. Administer calcium gluconate IV.
Correct Answer: D
Rationale: Administering calcium gluconate IV is the correct action when a client displays toxicity from magnesium sulfate. Calcium gluconate is used as the antidote for magnesium sulfate toxicity as it counteracts the effects. Positioning the client supine (Choice A) is not the immediate action needed. Administering dextrose 5% in water (Choice B) is not indicated for magnesium sulfate toxicity. Administering methylergonovine IM (Choice C) is used in postpartum hemorrhage, not for magnesium sulfate toxicity.
A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?
- A. Serous drainage at the incision site
- B. Temperature 38.2°C (100.8°F)
- C. Heart rate 92/min
- D. Blood pressure 130/80 mm Hg
Correct Answer: B
Rationale: The correct answer is B. An elevated temperature of 38.2°C (100.8°F) indicates a potential infection and should be reported to the provider. Elevated temperature postoperatively is often a sign of infection or inflammation, which can delay healing and increase the risk of complications. Choices A, C, and D are within normal ranges for a postoperative client and do not indicate an immediate need for reporting to the provider. Serous drainage at the incision site is expected in the initial postoperative period as part of the normal healing process, a heart rate of 92/min can be a normal response to surgery due to stress or pain, and a blood pressure of 130/80 mm Hg is also within normal limits for most clients.
A healthcare professional is reviewing the medication history of a client who has a new prescription for warfarin. Which of the following medications should the healthcare professional identify as a contraindication for this client?
- A. Acetaminophen
- B. Ibuprofen
- C. Clopidogrel
- D. Metoprolol
Correct Answer: C
Rationale: The correct answer is C, Clopidogrel. Clopidogrel is an antiplatelet medication that increases the risk of bleeding when taken with warfarin. Acetaminophen (choice A) and metoprolol (choice D) do not have significant interactions with warfarin. Ibuprofen (choice B) is an NSAID that can also increase the risk of bleeding when taken with warfarin, but clopidogrel is a more significant contraindication due to its antiplatelet effects. Therefore, healthcare professionals should be cautious when combining warfarin with clopidogrel due to the increased risk of bleeding compared to other options.
A healthcare provider is providing dietary teaching to a client who has osteoporosis. Which of the following foods should the healthcare provider recommend as the best source of calcium?
- A. Broccoli
- B. Cheddar cheese
- C. Almonds
- D. Fortified orange juice
Correct Answer: B
Rationale: Cheddar cheese is a rich source of calcium and should be recommended to clients with osteoporosis. While broccoli and almonds also contain calcium, cheddar cheese provides a higher amount per serving. Fortified orange juice may contain added calcium, but it is not as concentrated a source as cheddar cheese. Therefore, the best choice for a client with osteoporosis seeking a high calcium food is cheddar cheese.
A nurse is teaching a client who has a new prescription for clopidogrel. Which of the following statements should the nurse include?
- A. You should avoid drinking alcohol while taking this medication.
- B. You should monitor for signs of infection.
- C. Take this medication with food to prevent gastrointestinal upset.
- D. Take this medication with a full glass of water.
Correct Answer: B
Rationale: The correct statement the nurse should include when teaching a client taking clopidogrel is to monitor for signs of infection. Clopidogrel affects platelet levels and can increase the risk of bleeding. Monitoring for signs of infection is crucial because a compromised immune system can make the client more susceptible to infections. Choices A, C, and D are incorrect because clopidogrel is not directly linked to alcohol restrictions, food requirements, or specific water intake instructions.