Nokea
A primiparous client develops uterine atony and postpartum hemorrhage 1 hour after a vaginal delivery. The physician has ordered I.M. prostagland in F₂a. After administration of the medication, the nurse should observe the client for which of the following?
- A. Tachycardia
- B. Hypotension
- C. Constipation
- D. Fever
Correct Answer: A
Rationale: Prostaglandin-F2α can cause tachycardia as a side effect due to its stimulatory effects on smooth muscle. Hypotension, constipation, and fever are less commonly associated.
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The nurse teaches the client diagnosed with acute gouty arthritis about the prescribed indomethacin therapy. The nurse determines that there is a need for further teaching when the client makes which statement?
- A. I'll rest if I am having pain.
- B. I need to call the office if I notice a rash.
- C. I can take a pill whenever I need to for pain.
- D. I'll watch for indications that my feet or fingers are swollen.
Correct Answer: C
Rationale: Indomethacin may alleviate pain but is administered on a scheduled time frame, not on an as-needed schedule. Rest can be effective to relieve gouty arthritis pain. A rash could indicate hypersensitivity to the medication. The client should be instructed to monitor for swelling and gastric distress, which can be caused by the medication.
Which of these statements related to information technology is accurate?
- A. Social networks and cell phone cameras pose low risk in terms of information technology security and confidentiality.
- B. The security of technological data and information in healthcare environments is most often violated by those who work there.
- C. The security of technological data and information in healthcare environments is most often violated by computer hackers.
- D. Computer data deletion destroys all evidence of the data.
Correct Answer: B
Rationale: The most common breaches of healthcare data security occur internally by staff , through actions like unauthorized access or improper handling of information, rather than external hackers or low-risk social media . Data deletion does not always destroy all evidence.
Assessment of a client taking lithium reveals dry mouth, nausea, thirst, and mild hand tremor. Based on an analysis of these findings, which of the following should the nurse do next?
- A. Hold the lithium and obtain a stat lithium level to determine therapeutic effectiveness.
- B. Continue the lithium and immediately notify the physician about the assessment findings.
- C. Continue the lithium and reassure the client that these temporary side effects will subside.
- D. Hold the lithium and monitor the client for signs and symptoms of increasing toxicity.
Correct Answer: C
Rationale: These symptoms are common side effects of lithium, especially early in treatment, and typically subside as the body adjusts. Continuing the medication and reassuring the client is appropriate unless symptoms worsen.
The nurse is caring for a client with a history of peripheral arterial disease. Which of the following interventions should be included in the plan of care?
- A. Elevate the legs above heart level.
- B. Apply heating pads to the affected limbs.
- C. Encourage walking to tolerance.
- D. Restrict fluid intake.
Correct Answer: C
Rationale: Walking to tolerance improves collateral circulation in peripheral arterial disease.
Select the step of blood glucose level monitoring that is NOT accurate.
- A. Turn the finger down so the blood will drop with gravity.
- B. Wipe off the first drop of blood using sterile gauze.
- C. Prick the side of the finger using the lancet.
- D. Prick the pad of the finger using the lancet.
Correct Answer: D
Rationale: Pricking the pad of the finger is less accurate and more painful; the side of the finger is the preferred site for blood glucose monitoring.