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A nurse is providing discharge instructions to a client who has a new prescription for haloperidol. Which of the following adverse effects should the nurse instruct the client to report to the provider?
- A. Weight gain
- B. Dry mouth
- C. Shuffling gait
- D. Sedation
Correct Answer: C
Rationale: The correct answer is C: Shuffling gait. Haloperidol is an antipsychotic medication known to cause extrapyramidal side effects like shuffling gait, which can indicate a serious movement disorder called tardive dyskinesia. Reporting this symptom promptly to the provider is crucial for early intervention. Weight gain (A) and dry mouth (B) are common side effects of many medications, including haloperidol, but they are not considered urgent to report. Sedation (D) is a common side effect of haloperidol, but it is not typically a sign of a serious adverse reaction requiring immediate attention.
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Select the 5 actions the nurse should take.
- A. Increase the flowrate of the maintenance IV fluid
- B. Have the charge nurse notify the provider
- C. Place the client in a Trendelenburg position.
- D. Exert upward pressure on the presenting part.
- E. Attempt to push the umbilical cord back into the cervix
- F. Administer oxygen at 10 L/min via nonrebreather face mask
Correct Answer: B, C, D, E, F
Rationale: The correct actions (B, C, D, E, F) are based on managing a prolapsed umbilical cord during labor. B is crucial for timely intervention by involving the provider. C (Trendelenburg position) helps alleviate pressure on the cord. D (upward pressure) helps relieve compression on the cord. E aims to prevent cord compression. F (oxygen) supports fetal oxygenation. A is incorrect as increasing IV flowrate isn't a priority. G is not provided.
A nurse is teaching a client about family planning using the basal body temperature method. Which of the following instructions should the nurse include in the teaching?
- A. Take your temperature immediately after waking and before getting out of bed.'
- B. Take your temperature within 30 minutes after your first morning void.'
- C. Take your temperature 1 hour after getting out of bed.'
- D. Take your temperature every night before going to bed.'
Correct Answer: A
Rationale: The correct answer is A: "Take your temperature immediately after waking and before getting out of bed." This instruction is crucial for accurate basal body temperature tracking as it helps to capture the body's resting temperature before any physical activity or external factors can influence it. Option B is incorrect because taking the temperature after voiding may not provide the most accurate reading. Option C is incorrect as waiting one hour after getting out of bed can introduce variability in the readings. Option D is incorrect because taking the temperature at night before bed does not reflect the basal body temperature.
A nurse is providing teaching to a client who is at 14 weeks of gestation about findings to report to the provider. Which of the following findings should the nurse include in the teaching?
- A. Bleeding gums
- B. Faintness upon rising
- C. Urinary frequency
- D. Swelling of the face
Correct Answer: D
Rationale: The correct answer is D: Swelling of the face. At 14 weeks of gestation, facial swelling could indicate preeclampsia, a serious condition characterized by high blood pressure and protein in the urine. This finding should be reported to the provider immediately for further evaluation and management to prevent complications for both the mother and the baby.
Other choices are incorrect because:
A: Bleeding gums are common during pregnancy due to hormonal changes and increased blood flow to the gums.
B: Faintness upon rising may be due to postural hypotension, common in pregnancy.
C: Urinary frequency is a common complaint in early pregnancy due to hormonal changes and pressure on the bladder from the growing uterus.
The nurse is reviewing the assessment findings. For each assessment finding, click to specify if the finding is consistent with preeclampsia or HELLP syndrome. Each finding may support more than one disease process
- A. Hemoglobin
- B. Alanine aminotransferase (ALT)
- C. Blood pressure
- D. Platelet count
Correct Answer: C: Preeclampsia; A, B, D: HELLP
Rationale: The correct answer is: C: Preeclampsia; A, B, D: HELLP.
1. Blood pressure is consistent with preeclampsia as elevated blood pressure is a key characteristic.
2. Hemoglobin, Alanine aminotransferase (ALT), and Platelet count are consistent with HELLP syndrome, as these markers are commonly affected in this condition.
3. Preeclampsia is characterized by hypertension and proteinuria, while HELLP syndrome involves hemolysis, elevated liver enzymes, and low platelet count.
4. Therefore, based on the assessment findings provided, elevated blood pressure aligns with preeclampsia, while abnormalities in hemoglobin, ALT, and platelet count suggest HELLP syndrome.
A nurse is preparing to initiate intravenous fluids via infusion pump for a client. Which of the following actions should the nurse take?
- A. Obtain a surge protector that can accommodate the pump and several other appliances
- B. Verify that the extension cord for the pump is ungrounded
- C. Report the pump has a frayed cord and proceed with the infusion
- D. Check the expiration date on the safety inspection sticker of the pump
Correct Answer: D
Rationale: The correct answer is D: Check the expiration date on the safety inspection sticker of the pump. This is crucial for ensuring the safety and efficacy of the pump. Checking the expiration date ensures that the pump has been recently inspected and is functioning properly, reducing the risk of malfunctions.
A: Obtaining a surge protector is important for electrical safety, but it is not directly related to the specific task of initiating intravenous fluids via an infusion pump.
B: Verifying that the extension cord is ungrounded is unsafe as it increases the risk of electrical hazards.
C: Reporting a frayed cord is essential for patient safety, but proceeding with the infusion without addressing the issue is dangerous.
E, F, G: No information provided.