Nokea
Jane Love, a 35-year old gravida III para II at 23 weeks gestation, is seen in the Emergency Department with painless, bright red vaginal bleeding. Jane reports that she has been feeling tired and has noticed ankle swelling in the evening. Laboratory tests reveal a hemoglobin level of 11.5 g/dL. After evaluating the situation, the nurse determines that Jane is at risk for placenta previa, based on which of the following data?
- A. anemia
- B. edema
- C. painless vaginal bleeding
- D. fatigue
Correct Answer: C
Rationale: Painless, bright red vaginal bleeding in the second or third trimester is a hallmark of placenta previa, where the placenta covers the cervical os, causing bleeding as the uterus grows.
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The nurse completes teaching the client who has PD about taking benztropine. Which statements made by the client indicate that teaching is effective? Select all that apply.
- A. I plan to crush the tablets so that they are easier to swallow.
- B. I should refrain from taking over-the-counter medications.
- C. Once my symptoms improve, I can stop taking benztropine.
- D. Benztropine can cause drooling and excessive secretions.
- E. I should avoid driving until I know how benztropine affects me.
Correct Answer: A,B,E
Rationale: A: Benztropine (Cogentin) may be crushed; this statement indicates teaching is effective. B: Many OTC medications contain alcohol. Alcohol should be avoided because it is another CNS depressant, and additive drowsiness can occur. This statement indicates teaching is effective. C: Benztropine should not be abruptly discontinued; symptoms will recur, and it may precipitate parkinsonian crisis. D: Benztropine is an anticholinergic that will cause a dry mouth, not drooling and increased secretions. E: Because benztropine (Cogentin) is a CNS depressant, driving should be avoided until the effects of the medication are known. This statement indicates teaching is effective.
The nurse is preparing to administer IV fluids to the 13-kg child who has dehydration. The daily IV fluid requirement is to administer 1000 mL / 50 mL/kg over 10 kg. How many milliliters per hour should the nurse calculate to administer the IV therapy correctly?
Correct Answer: 48
Rationale: This child weighs 13 kg; the daily requirement is 1000 mL + (50 mL x 3) = 1150 mL/24 hr. The hourly rate is 1150 mL/ 24 hr = 47.9167 mL/hr, rounded to 48 mL/hr.
The nurse is discussing the prescribed atypical antipsychotic medication therapy with the client with schizophrenia. What information should the nurse include in this discussion? Select all that apply.
- A. Atypical antipsychotic medications will affect the client's hallucinations and inappropriate emotional responses.
- B. Atypical antipsychotic medications are prescribed after other medications have proven ineffective in treating symptoms.
- C. The greatest concern with taking atypical antipsychotic medications is that they produce extrapyramidal side effects.
- D. Regular laboratory appointments will need to be scheduled to monitor the client's blood glucose levels.
- E. The client may experience an increase in appetite and weight gain when taking an atypical antipsychotic medication.
Correct Answer: A,D,E
Rationale: Atypical antipsychotics target hallucinations and emotional responses, require blood glucose monitoring, and may cause increased appetite and weight gain.
The nurse is preparing to administer medications at 1700 to multiple clients with GI problems. Which medication should be the nurse's priority when the meal trays are due to arrive at 1700?
- A. Misoprostol
- B. Famotidine
- C. Cimetidine
- D. Bisacodyl
Correct Answer: A
Rationale: A: The nurse's priority should be to administer misoprostol (Cytotec), a gastric protectant, first because it should be taken with meals to minimize diarrhea. B: Famcomputers (Pepcid), a histamine receptor agonist, should be taken after meals. C: Cimetidine (Tagamet HB), a histamine receptor agonist, should be taken after meals. D: Bisacodyl (Dulcolax), a laxative, should be taken at least one hour after meals.
A nurse working a surgical unit, notices a patient is experiencing SOB, calf pain, and warmth over the posterior calf. All of these may indicate which of the following medical conditions?
- A. Patient may have a DVT.
- B. Patient may be exhibiting signs of dermatitis.
- C. Patient may be in the late phases of CHF.
- D. Patient may be experiencing anxiety after surgery.
Correct Answer: A
Rationale: All of these factors (SOB, calf pain, and warmth) indicate a deep vein thrombosis (DVT), which can be a postoperative complication.