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A nurse is collecting data from a client who is at 32 weeks of gestation and is experiencing preterm labor. Which of the following findings should the nurse expect?
- A. The client reports a tightening of her abdomen.
- B. The client reports increased urinary output.
- C. The client reports a temperature of 38.9°C (102°F).
- D. The client reports seeing bright red blood.
Correct Answer: A
Rationale: A tightening of the abdomen indicates uterine contractions, a hallmark of preterm labor, which the nurse should expect at 32 weeks of gestation.
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A nurse is reinforcing teaching with a client who has a new prescription for hydrocortisone cream. Which of the following instructions should the nurse include?
- A. Apply a thick layer to the affected area.
- B. Cover the area with an occlusive dressing.
- C. Apply the cream to open wounds.
- D. Use the cream sparingly.
Correct Answer: D
Rationale: Using hydrocortisone cream sparingly minimizes systemic absorption and reduces the risk of side effects like skin thinning.
A nurse is caring for a client who has a new diagnosis of Bell's palsy. Which of the following findings should the nurse expect?
- A. Facial drooping
- B. Weight gain
- C. Bradycardia
- D. Hypotension
Correct Answer: A
Rationale: Facial drooping, typically unilateral, is a hallmark symptom of Bell's palsy due to facial nerve paralysis.
A nurse is caring for a client who has a new prescription for duloxetine. Which of the following adverse effects should the nurse monitor for?
- A. Insomnia
- B. Weight loss
- C. Bradycardia
- D. Hypoglycemia
Correct Answer: A
Rationale: Duloxetine, an SNRI, can cause insomnia due to its effect on serotonin and norepinephrine levels.
A nurse is monitoring a client's lower extremity following the placement of a cast earlier in the day. Which of the following findings should the nurse identify as manifestations of compartment syndrome? (Select all that apply.)
- A. Pale-colored toes
- B. Decreased skin turgor
- C. Pain relieved by analgesia
- D. Diminished capillary refill
- E. Sensation of tingling
Correct Answer: A,D,E
Rationale: Pale-colored toes are a sign of compromised circulation, which is a key manifestation of compartment syndrome. Decreased blood flow to the affected limb can cause pallor, which requires immediate intervention to prevent permanent damage. Diminished capillary refill is correct. Delayed capillary refill (longer than 2 seconds) suggests poor perfusion, which can indicate increased pressure within the compartment. Sensation of tingling is correct. Paresthesia (tingling or numbness) is an early sign of nerve compression due to swelling within the compartment. If untreated, this can progress to permanent nerve and muscle damage.
A nurse is reinforcing teaching with a client who is scheduled for a sigmoidoscopy. Which of the following instructions should the nurse include?
- A. Fast for 12 hours before the procedure.
- B. Use an enema the evening before.
- C. Expect general anesthesia.
- D. Avoid drinking fluids after the procedure.
Correct Answer: B
Rationale: Using an enema the evening before a sigmoidoscopy clears the lower colon for a clear view during the procedure.