Nokea
Prior to a cesarean section delivery, a 24-year-old woman is treated for abruptio placentae. The nurse is caring for the woman during the postpartum period. Which of the following symptoms would be suggestive of disseminated intravascular coagulation (DIC)?
- A. The client's vital signs are: BP 90/58, temperature 101°F (38.3°C), pulse 112, respirations 18.
- B. The client's laboratory results are: Hgb 13 g/dL, Hct 40%, WBC 7,000/mm³.
- C. The client is nauseated, lethargic, and has vomited three times.
- D. There is oozing blood from the venipuncture site and abdominal incision.
Correct Answer: D
Rationale: DIC is acquired clotting disorder from overstimulation, prolonged oozing from sites of minor trauma first symptom
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A 45-year-old client with newly diagnosed IDDM (insulin-dependent diabetes mellitus) is being seen by the home health nurse. The physician has placed him on a 1,800-calorie ADA diet, ordered the client to self-administer 15 units of NPH insulin each day before breakfast, and check his blood sugar qid. When the nurse visits the client at 5 PM, the nurse discovers that the client has not eaten since noon and has just returned from jogging. The client's vital signs are: BP 110/80, pulse 120, respirations 18, temperature 98.2°F (36.8°C). When the client obtains his blood sugar reading, the nurse would expect it to be?
- A. 250 mg/dL.
- B. 160 mg/dL.
- C. 90 mg/dL.
- D. 50 mg/dL.
Correct Answer: D
Rationale: hypoglycemia symptoms are cool, clammy skin, diaphoresis, nervousness, weakness, hunger, confusion, headache, slurred speech, coma
A middle-aged female client begins outpatient therapy sessions with a psychiatric clinical nurse specialist for management of a phobic disorder. Which of the following nursing interventions should be an initial approach in symptom reduction?
- A. Referral for psychopharmacologic intervention.
- B. Group psychotherapy.
- C. Systematic desensitization.
- D. Biofeedback.
Correct Answer: C
Rationale: phobic disorders are learned responses; learned responses can be unlearned through certain techniques, such as behavioral modification; systematic desensitization is a form of behavior modification; is a strategy used in conjunction with deep muscle relaxation to decrease the extreme response to anxiety-producing situations as they are gradually exposed; then exposure is increased; goal is to eradicate the phobic response by replacing it with the relaxation response
The nurse is supervising a student nurse teach a client about a newly prescribed medication. Which of the following actions, if observed by the nurse, would require an intervention?
- A. The student nurse glances at his/her watch when instructing the client.
- B. The student nurse uses culturally appropriate language and teaching materials.
- C. The student nurse begins instructions to the client discussing information that concerns the client.
- D. The student nurse chooses a time for teaching when there are no visitors.
Correct Answer: A
Rationale: lack of attending behaviors are always a barrier to learning
A 36-year-old man has a flaccid bladder following a spinal cord injury. The nurse is teaching the client about dietary changes. Which of the following beverages, if selected by the client, would indicate to the nurse that teaching was effective?
- A. Lemonade.
- B. Prune juice.
- C. Milk.
- D. Orange juice.
Correct Answer: B
Rationale: promotes acidic urine, minimizes risk of urinary tract infection and stone formation, also use cranberry, tomato juice, bouillon
A client is receiving a blood transfusion. Fifteen minutes after the transfusion begins, the client develops a fever and chills. Which of the following actions should the nurse take FIRST?
- A. Stop the transfusion immediately.
- B. Notify the physician.
- C. Administer acetaminophen.
- D. Increase the infusion rate.
Correct Answer: A
Rationale: fever and chills may indicate a transfusion reaction, and the transfusion must be stopped immediately