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A pregnant client reports that her last menstrual period was February 9, 2018. Using Nägele's rule, what will the nurse determine as the estimated date of birth?
- A. 7-Oct-18
- B. 16-Oct-18
- C. 7-Nov-18
- D. 16-Nov-18
Correct Answer: D
Rationale: Accurate use of Nägele's rule requires that the woman has a regular 28-day menstrual cycle. To calculate the estimated date of birth, the nurse would subtract 3 months from the first day of the last menstrual period, add 7 days, and then adjust the year as appropriate. First day of last menstrual period: February 9, 2018; subtract 3 months: November 9, 2017; add 7 days: November 16, 2017; and add 1 year, November 16, 2018.
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A client is receiving cisplatin. On assessment of the client, which findings indicate that the client is experiencing an adverse effect of the medication?
- A. Tinnitus
- B. Increased appetite
- C. Excessive urination
- D. Yellow halos in front of the eyes
Correct Answer: A
Rationale: Cisplatin is an antineoplastic medication. An adverse effect related to the administration of cisplatin is ototoxicity with hearing loss. The nurse should assess for this adverse reaction when administering this medication. Options 2, 3, and 4 are not adverse effects of this medication.
The home health nurse is performing an initial assessment on a client who has been discharged after an insertion of a permanent pacemaker. Which client statement indicates that an understanding of self-care is evident?
- A. I will never be able to operate a microwave oven again.
- B. I should expect occasional feelings of dizziness and fatigue.
- C. I will take my pulse in the wrist or neck daily and record it in a log.
- D. Moving my arms and shoulders vigorously helps check pacemaker functioning.
Correct Answer: C
Rationale: Clients with permanent pacemakers must be able to take their pulse in the wrist and/or neck accurately so as to note any variation in the pulse rate or rhythm that may need to be reported to the primary health care provider. Clients can safely operate most appliances and tools, such as microwave ovens, video recorders, AM-FM radios, electric blankets, lawn mowers, and leaf blowers, as long as the devices are grounded and in good repair. If the client experiences any feelings of dizziness, fatigue, or an irregular heartbeat, the primary health care provider is notified. The arms and shoulders should not be moved vigorously for 6 weeks after insertion.
The nurse has just finished assisting the primary health care provider in placing a central intravenous (IV) line. Which is a priority intervention to assure the client's safety?
- A. Assessing the client's pain level
- B. Assessing the client's temperature
- C. Preparing the client for a chest x-ray
- D. Monitoring the client's blood pressure (BP)
Correct Answer: C
Rationale: A major risk associated with central line placement is the possibility of a pneumothorax developing from an accidental puncture of the lung. Assessing the results of a chest radiograph is one of the best methods to determine if this complication has occurred and verify catheter tip placement before initiating IV therapy. A temperature elevation related to central line insertion would not likely occur immediately after placement. Pain management is important but is not the priority at this point. Although BP assessment is always important in assessing a client's status after an invasive procedure, fluid volume overload is not a concern until IV fluids are started.
The nurse has a prescription to administer hydroxyzine to a client by the intramuscular route. Before administering the medication, what information should the nurse share with the client?
- A. Excessive salivation is a side effect.
- B. There will be some pain at the injection site.
- C. There should be relief from nausea within 5 minutes.
- D. The client may experience increased agitation for about 2 hours.
Correct Answer: B
Rationale: Hydroxyzine is an antiemetic and sedative/hypnotic that may be used in conjunction with opioid analgesics for added effect. The injection can be painful. Hydroxyzine causes dry mouth and drowsiness as side effects. Agitation is not a usual side effect. Medications administered by the intramuscular route generally take 20 to 30 minutes to become effective.
A client with a posterior wall bladder injury has had surgical repair and placement of a suprapubic catheter. What intervention should the nurse plan to implement to prevent complications associated with the use of this catheter?
- A. Monitor urine output every shift.
- B. Measure specific gravity once a shift.
- C. Encourage a high intake of oral fluids.
- D. Avoid kinking of the catheter tubing.
Correct Answer: D
Rationale: A complication after surgical repair of the bladder is disruption of sutures caused by tension on them from urine buildup. The nurse prevents this from happening by ensuring that the catheter is able to drain freely. This involves basic catheter care, including keeping the tubing free from kinks, keeping the tubing below the level of the bladder, and monitoring the flow of urine frequently. Monitoring urine output every shift is insufficient to detect decreased flow from catheter kinking. Measurement of urine specific gravity and a high oral fluid intake do not prevent complications of bladder surgery.