Nokea
After explaining to a multigravid client at 36 weeks' gestation who is diagnosed with severe hydramnios about the possible complications of this condition, which of the following statements indicates that the client needs further instruction?
- A. Because I have hydramnios, I may gain weight.'
- B. Hydramnios has been associated with gastrointestinal disorders in the fetus.'
- C. I should continue to eat high-fiber foods and avoid constipation.'
- D. I can continue to work at my job at the automobile factory until labor starts.'
Correct Answer: D
Rationale: Severe hydramnios increases risks like preterm labor, requiring activity restrictions; continuing physically demanding work indicates a need for further teaching.
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A client with a history of breast cancer is prescribed anastrozole (Arimidex). The nurse should monitor the client for which of the following adverse effects?
- A. Bone loss.
- B. Hyperglycemia.
- C. Hypertension.
- D. Weight gain.
Correct Answer: A
Rationale: Anastrozole, an aromatase inhibitor, can cause bone loss, increasing osteoporosis risk.
The nurse assesses a client and notes that he has a weak, irregular pulse, as well as soft, flabby muscles. The nurse should assess the client further for:
- A. Hypercalcemia.
- B. Hypernatremia.
- C. Hypokalemia.
- D. Hypomagnesemia.
Correct Answer: C
Rationale: Weak, irregular pulse and flabby muscles are signs of hypokalemia, which affects muscle and cardiac function. The other conditions present differently.
The nurse is caring for a client with a history of peripheral artery disease. Which of the following interventions is most appropriate?
- A. Keep the legs elevated above heart level.
- B. Encourage prolonged standing.
- C. Apply warm compresses to the legs.
- D. Promote regular walking.
Correct Answer: D
Rationale: Regular walking promotes collateral circulation in peripheral artery disease, improving blood flow.
The nurse is providing bottle-feeding instructions to the mother of a newborn infant. The nurse provides instructions regarding the amount of formula to be given, knowing that what is the approximate stomach capacity for a newborn?
- A. 5 to 10 mL
- B. 10 to 20 mL
- C. 30 to 90 mL
- D. 75 to 100 mL
Correct Answer: B
Rationale: The stomach capacity of a newborn is approximately 10 to 20 mL. It is 30 to 90 mL for a 1-week-old infant and 75 to 100 mL for a 2- to 3-week-old infant.
A client with a history of chronic kidney disease is prescribed sevelamer (Renagel). The nurse should instruct the client to:
- A. Take the medication with meals.
- B. Take the medication on an empty stomach.
- C. Avoid taking the medication with calcium supplements.
- D. Stop the medication if constipation occurs.
Correct Answer: A
Rationale: Sevelamer should be taken with meals to bind phosphate in the gut.