Nokea
During a prenatal visit, a client states: 'I have been very nauseated during my first trimester, and I don't understand the reason.' Which of the following responses by the nurse is BEST?
- A. You are nauseated because of the fatigue you are feeling.'
- B. The nausea is due an increase in the basal metabolic rate.'
- C. The nausea is caused by a secondary elevation in the hormones produced by the endocrine system.'
- D. If you eat different kinds of foods, you won't be nauseated.'
Correct Answer: C
Rationale: during first trimester, nausea and vomiting are related to elevation in estrogen, progesterone, and hCG from the endocrine system
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The nurse is caring for a client with pancreatitis experiencing the process of lipolysis of the pancreas. Which assessment would be a priority because of the pathophysiology of lipolysis?
- A. Checking for tetany-like movements
- B. Assessing breath sounds
- C. Obtaining vital signs
- D. Palpating pedal pulses
Correct Answer: A
Rationale: Hypocalcemia is a specific manifestation of clients with pancreatitis and lipolysis, and tetany is a major characteristic of low calcium levels. Answers B, C, and D are all pertinent assessments but are not priorities with the pathophysiology of lipolysis, so they are incorrect.
The nurse is administering lidocaine (Xylocaine) to a client with a myocardial infarction. Which of the following assessment findings requires the nurse's immediate action?
- A. Central venous pressure reading of 11
- B. Respiratory rate of 22
- C. Pulse rate of 48 BPM
- D. Blood pressure of 144/92
Correct Answer: C
Rationale: One of the side effects of lidocaine is bradycardia, heart block, cardiovascular collapse, and cardiac arrest (this drug should never be administered without continuous EKG monitoring).
The nurse is assessing a client immediately after an exploratory laparotomy. Which of the following nursing observations would relate to the complication of inTest inal obstruction?
- A. Protruding soft abdomen with frequent diarrhea.
- B. Distended abdomen with ascites.
- C. Minimal bowel sounds in all four quadrants.
- D. Distended abdomen with complaints of pain.
Correct Answer: D
Rationale: if an obstruction is present, the abdomen will become distended and painful
An adult client with a nasogastric tube has an order for acetaminophen (Tylenol) 650 mg PRN for a temperature greater than 101°F (38.3°C).
Which of the following measures should be included by the nurse when administering this medication?
- A. The tablets should be swallowed carefully with sips of water.
- B. The medication should be withheld until the nasogastric tube is removed.
- C. Placement of the nasogastric tube should be checked prior to giving the medication.
- D. Powdered medication should be used and mixed with water to form a solution.
Correct Answer: C
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) client is NPO, so nothing should be administered orally (2) medication should not be withheld (3) correct-liquid acetaminophen may be administered via the nasogastric tube after tube placement has been checked; tube placement should be checked before anything is instilled (4) Tylenol does not come powdered
Which of the following meal choices is suitable for a 6-month-old infant?
- A. Egg white, formula, and orange juice
- B. Apple juice, carrots, and whole milk
- C. Rice cereal, formula, and apple juice
- D. Melba toast, egg yolk, and whole milk
Correct Answer: C
Rationale: Rice cereal, formula, and apple juice are appropriate for a 6-month-old, as they are easily digestible and safe. Egg whites, whole milk, and orange juice are not recommended before 1 year due to allergy and digestive risks.