Nokea
A pregnant woman is hospitalized for treatment of pregnancy induced hypertension (PIH) in the third trimester. She is receiving magnesium sulfate intravenously. The nurse understands that this medication is used mainly for what purpose?
- A. Maintain normal blood pressure
- B. Prevent convulsive seizures
- C. Increase the respiratory rate
- D. Increase uterine blood flow
Correct Answer: B
Rationale: Prevent convulsive seizures. Magnesium sulfate is a central nervous system depressant. While it has many systemic effects, it is used in the client with pregnancy induced hypertension (PIH) to prevent seizures.
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A 4 year-old child is admitted with burns on his legs and lower abdomen. When assessing the child's hydration status, which of the following indicates a less than adequate fluid replacement?
- A. Decreasing hematocrit and increasing urine volume
- B. Rising hematocrit and decreasing urine volume
- C. Falling hematocrit and decreasing urine volume
- D. Stable hematocrit and increasing urine volume
Correct Answer: B
Rationale: Rising hematocrit and decreasing urine volume. A rising hematocrit indicates a decreased total blood volume, a finding consistent with dehydration.
The client diagnosed with status asthmaticus is prescribed intravenous aminophylline, a bronchodilator. Which assessment data would warrant immediate intervention?
- A. The theophylline level is 12 mcg/mL.
- B. The client has expiratory wheezing.
- C. The client complains of muscle twitching.
- D. The client is refusing to eat the meal.
Correct Answer: C
Rationale: Muscle twitching indicates theophylline toxicity, requiring immediate intervention. Normal levels (10–20 mcg/mL), wheezing, or meal refusal are expected or less urgent.
The client is receiving a loop diuretic for congestive heart failure. Which medication would the nurse expect the client to be receiving while taking this medication?
- A. A potassium supplement.
- B. A cardiac glycoside.
- C. An ACE inhibitor.
- D. A potassium cation.
Correct Answer: A
Rationale: Loop diuretics like furosemide cause potassium loss; supplements prevent hypokalemia, a common need in CHF.
The client in the emergency department requires sutures for a laceration on the left leg. Which information is most pertinent prior to suturing the wound?
- A. The client tells the nurse she has never had sutures.
- B. The spouse refuses to leave the room during suturing.
- C. The client shares she is scared of needles.
- D. The client reports hives after having dental surgery.
Correct Answer: D
Rationale: Hives post-dental surgery suggest a possible local anesthetic allergy, critical to know before suturing to avoid anaphylaxis.
The nurse is caring for an elderly client who is eight (8) hours postoperative hip replacement and is reporting incisional pain. Which intervention is priority for this client?
- A. Assist the client to sit in the bedside chair.
- B. Initiate pain medication at the lowest dose.
- C. Assess the client's pupil size and accommodation.
- D. Monitor the client's urinary output hourly.
Correct Answer: B
Rationale: Pain management is the priority post-op to promote recovery and comfort; lowest dose minimizes side effects in the elderly. Sitting, pupil assessment, or urine output are secondary.