Nokea
A nurse is caring for a client who is receiving an epidural block with an opioid analgesic. The nurse should monitor for which of the following findings as an adverse effect of the medication?
- A. Hypnosis
- B. Polyuria
- C. Bilateral crackles
- D. Hyperglycemia
Correct Answer: C
Rationale: The correct answer is C: Bilateral crackles. When a client is receiving an opioid analgesic via an epidural block, a potential adverse effect is respiratory depression, leading to the accumulation of fluid in the lungs and the development of bilateral crackles upon auscultation. Hypnosis (choice A) is not typically associated with opioid analgesics. Polyuria (choice B) is not a common side effect of opioids or epidural blocks. Hyperglycemia (choice D) is not a direct adverse effect of opioid analgesics administered through an epidural block. Monitoring for bilateral crackles is crucial to detect and address respiratory depression promptly.
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The nurse is caring for a postpartum client who reports feeling overwhelmed and tearful. What is the nurse's priority intervention?
- A. Administer a sedative as prescribed.
- B. Encourage the client to rest and sleep.
- C. Provide emotional support and reassurance.
- D. Refer the client to a mental health professional.
Correct Answer: C
Rationale: The correct answer is C: Provide emotional support and reassurance. This is the priority intervention because the client is feeling overwhelmed and tearful, indicating a need for immediate emotional support. Administering a sedative (A) may mask the underlying issue and is not addressing the client's emotional needs. Encouraging rest and sleep (B) is important but secondary to addressing the client's emotional state. Referring the client to a mental health professional (D) may be necessary in the long term but is not the immediate priority in this situation. Emotional support and reassurance can help the client feel validated and supported in the moment.
A client with a history of hypertension is at 28 weeks' gestation. What complication is she at greatest risk for?
- A. Placenta previa.
- B. Gestational diabetes.
- C. Abruptio placentae.
- D. Preterm labor.
Correct Answer: C
Rationale: The correct answer is C: Abruptio placentae. At 28 weeks, the client with hypertension is at greater risk for abruptio placentae due to increased vascular resistance, leading to potential placental detachment. Placenta previa (A) is more common in the third trimester. Gestational diabetes (B) is more common in later pregnancy and not directly related to hypertension. Preterm labor (D) can be a risk with chronic hypertension but is not the greatest risk at 28 weeks.
The nurse is caring for a postpartum client with excessive bleeding. What is the priority nursing intervention?
- A. Administer IV fluids.
- B. Massage the uterine fundus.
- C. Notify the healthcare provider.
- D. Check the client's vital signs.
Correct Answer: B
Rationale: The correct answer is B: Massage the uterine fundus. This is the priority intervention because excessive bleeding postpartum may indicate uterine atony, which can lead to hemorrhage. Massaging the uterine fundus helps to stimulate uterine contractions and control bleeding. Administering IV fluids (A) can be important, but controlling bleeding takes precedence. Notifying the healthcare provider (C) can be done after implementing immediate interventions. Checking vital signs (D) is important, but addressing the underlying cause of bleeding is the priority.
What component of a health history for a wellness exam includes information on lifestyle factors, such as diet, exercise habits, tobacco use, alcohol consumption, and recreational drug use?
- A. chief complaint/reason for visit
- B. gynecologic history
- C. medications and supplements
- D. social history
Correct Answer: D
Rationale: The correct answer is D: social history. This component of a health history focuses on lifestyle factors that can impact a person's overall health and well-being. It includes information on diet, exercise habits, tobacco use, alcohol consumption, and recreational drug use. By understanding these factors, healthcare providers can assess potential risks, provide appropriate counseling, and tailor interventions to promote health.
A: Chief complaint/reason for visit is not the correct answer as it pertains to the specific reason why the patient is seeking medical attention.
B: Gynecologic history is focused on a specific aspect of health related to female reproductive health and is not inclusive of overall lifestyle factors.
C: Medications and supplements focus on the use of medications and supplements and do not cover lifestyle factors such as exercise habits or recreational drug use.
The nurse is assessing a client in active labor with variable decelerations on the fetal monitor. What is the priority intervention?
- A. Increase oxytocin infusion.
- B. Reposition the client.
- C. Administer oxygen at 10 L/min.
- D. Perform a vaginal examination.
Correct Answer: B
Rationale: The correct answer is B: Reposition the client. Variable decelerations can indicate umbilical cord compression. Repositioning the client can help relieve the compression, improving fetal oxygenation. Increasing oxytocin (A) could worsen the situation. Administering oxygen (C) may be needed but repositioning is the priority. Performing a vaginal examination (D) is not indicated for variable decelerations.