Nokea
An elective saline abortion has been performed on a 3-week primigravida. Following the procedure, the nurse should be alert for which early side effect?
- A. Water satiety
- B. Thirst
- C. Edema
- D. Diabetes insipidus
Correct Answer: B
Rationale: Saline absorption into the bloodstream increases serum sodium, leading to thirst as an early side effect.
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A client with cystic fibrosis exhibits activity intolerance related to the pulmonary problems associated with his disease. However, he needs to be encouraged to participate in daily physical exercise. The ultimate aim of exercise is to:
- A. Create a sense of well-being and self-worth
- B. Help him overcome respiratory infections
- C. Establish an effective, habitual breathing pattern
- D. Promote normal growth and development
Correct Answer: C
Rationale: Physical exercise is an important adjunct to chest physiotherapy. It stimulates mucus secretion, promotes a feeling of well-being, and helps to establish a habitual breathing pattern.
The 4th of July holiday comes while a client is in the hospital being treated for schizophrenia. She is taking chlorpromazine and has improved to the point of being allowed to go with a group to the park for a picnic. The side effect of chlorpromazine that the nurse needs to keep in mind during this outing is:
- A. Hypotension
- B. Photosensitivity
- C. Excessive appetite
- D. Dryness of the mouth
Correct Answer: B
Rationale: Protection from the sun is important in clients taking phenothiazines like chlorpromazine because they burn easily and severely.
An elderly patient has been taking 80 mg of furosemide (Lasix) bid. The nurse notes that the patient's most recent potassium level is 2.5mEq/L. The nurse should:
- A. Continue the medication as ordered
- B. Administer the morning dose only
- C. Give the medication with orange juice
- D. Withhold the medication and notify the physician
Correct Answer: D
Rationale: A potassium level of 2.5 mEq/L indicates hypokalemia, a serious side effect of furosemide, a potassium-wasting diuretic. The nurse should withhold the medication and notify the physician to address the electrolyte imbalance.
A burn victim's immunization history is assessed by the nurse. Which immunization is of priority concern?
- A. Oral poliovirus vaccine
- B. Inactivated poliovirus vaccine
- C. Tetanus toxoid
- D. Hepatitis B vaccine
Correct Answer: C
Rationale: Tetanus toxoid prevents tetanus. Tetanus is transmitted through contaminated wounds.
A client with a history of a stroke is being discharged. The nurse should teach the client to:
- A. Avoid all physical activity
- B. Use assistive devices as needed
- C. Limit social interactions
- D. Eat a high-sodium diet
Correct Answer: B
Rationale: Assistive devices (e.g., cane, walker) promote safety and mobility post-stroke. Physical activity is encouraged, social interactions are beneficial, and sodium should be limited.