Nokea
A primiparous client at 48 hours postpartum is to be given medroxyprogesterone acetate (Depo-Provera) before discharge. Which of the following should the nurse include in the teaching plan before administering this medication?
- A. There is an increased risk of ovarian cancer with use of this drug.
- B. Amenorrhea is common during the first 6 months.
- C. Heavy menstrual bleeding may occur.
- D. The client may experience periods of increased energy.
Correct Answer: B
Rationale: Amenorrhea is a common side effect of Depo-Provera, especially in the first 6 months, and should be included in client teaching. The other options are incorrect.
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The nurse is caring for a client who has just undergone a total hip replacement. Which of the following positions should the nurse avoid placing the client in?
- A. Supine with legs crossed.
- B. Semi-Fowler's position.
- C. Side-lying with a pillow between the legs.
- D. Supine with the legs abducted.
Correct Answer: A
Rationale: Crossing the legs post-hip replacement risks dislocation of the prosthesis and should be avoided.
A client has received electroconvulsive therapy (ECT). What intervention should the nurse perform first in the posttreatment area and upon the client's awakening?
- A. Assist the client from the stretcher to a wheelchair.
- B. Orient the client and monitor his or her vital signs.
- C. Offer the client frequent reassurance and repeat orientation statements.
- D. Assess for a gag reflex so that the client can eat and drink with safety.
Correct Answer: B
Rationale: The nurse should first monitor vital signs, orient the client, and review with the client that he or she just received an ECT treatment. The posttreatment area should include accessibility to the anesthesia staff, oxygen, suction, pulse oximeter, vital sign monitoring, and emergency equipment. The nursing interventions outlined in the remaining options will follow accordingly.
A family has been notified that their son is brain dead, and the physician has discussed the possibility of donating organs. The nurse should collaborate with the physician to contact which referral source that is responsible for organ recovery in the United States?
- A. Organ and Tissue Procurement Organizations.
- B. American Transplant Association.
- C. American Hospice Foundation.
- D. American Association of Critical-Care Nurses.
Correct Answer: A
Rationale: Organ and Tissue Procurement Organizations are responsible for coordinating organ recovery in the United States, as they manage the donation process and ensure compliance with regulations.
A 4-year-old child is admitted with dehydration due to gastroenteritis. Which assessment finding indicates severe dehydration?
- A. Dry mucous membranes
- B. Decreased urine output
- C. Sunken fontanelles
- D. Tachycardia
Correct Answer: C
Rationale: Sunken fontanelles in a young child are a sign of severe dehydration, indicating significant fluid loss requiring urgent rehydration.
The nurse is delivering care to a client who is diagnosed with toxic shock syndrome (TSS). Which complication of this syndrome should the nurse monitor the client for?
- A. Pulmonary embolism
- B. Vitamin K deficiency
- C. Factor VIII deficiency
- D. Disseminated intravascular coagulopathy (DIC)
Correct Answer: D
Rationale: TSS is caused by infection and is often associated with tampon use. DIC is a complication of TSS. The nurse monitors the client for signs of this complication, and notifies the primary health care provider promptly if signs and symptoms are noted. The other options are not complications of TSS.