Before giving a client oral combination contraceptives, which side effects should the nurse tell the patient to be aware of? Select one that does not apply.
- A. Irregular bleeding
- B. Thick vaginal discharge
- C. Nausea
- D. Breast tenderness
Correct Answer: B
Rationale: The common side effects of oral combination contraceptives include irregular bleeding, nausea, and breast tenderness. Choice B is incorrect because thick vaginal discharge is not a typical side effect of oral contraceptives.
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A nurse is caring for a client who is in labor and has an epidural for pain control. Which of the following clinical ... effect of epidural anesthesia?
- A. Polyuria
- B. Hypertensi on
- C. Pruritus
- D. Dry mouth
Correct Answer: C
Rationale: Epidural anesthesia can result in some common side effects, one of which is pruritus (itching). Pruritus is a known side effect of the local anesthetics used in epidural anesthesia and is due to their effects on specialized receptors in the nervous system. Patients may experience itching, especially in the face, neck, and upper chest areas. Polyuria (increased urine output), hypertension (high blood pressure), and dry mouth are not typically associated side effects of epidural anesthesia.
A 35-year-old patient comes to the clinic 2 days after a tubal ligation. She complains of abdominal pain and swelling and redness at the surgical incision. What does the nurse know is a common complication of this procedure?
- A. Ileus
- B. Liver enlargement
- C. Constipation
- D. Infection
Correct Answer: D
Rationale: Infection is a common complication after tubal ligation, indicated by redness and swelling at the surgical site. Choice A is incorrect as ileus is a bowel obstruction, not typically a complication of tubal ligation. Choice B, liver enlargement, is unrelated to tubal ligation. Choice C, constipation, may be a side effect but is not a primary concern after this procedure.
The nurse is educating a patient on what constitutes IPV. What is an example of an act of IPV?
- A. child endangerment
- B. stalking
- C. workplace harassment
- D. legal allegations
Correct Answer: B
Rationale: Stalking is a deliberate act where the perpetrator repeatedly follows, harasses, or intimidates the victim, which can instill fear or threaten safety. It is recognized as a specific form of intimate partner violence (IPV).
A nurse is admitting a client who is at 33 weeks of gestation and has preeclampsia with severe features. Which of the following actions should the nurse take?
- A. Restrict protein intake to less than 40 g/day.
- B. Initiate seizure precautions for the client.
- C. Initiate an infusion of 0.9% sodium chloride at 150 mL/hr.
- D. Encourage the client to ambulate twice per day.
Correct Answer: B
Rationale: In a client with preeclampsia with severe features at 33 weeks of gestation, initiating seizure precautions is a priority nursing action. Preeclampsia with severe features places the client at an increased risk for seizures. Therefore, the nurse should ensure that seizure precautions are in place, such as maintaining a safe environment, pad the side rails of the bed, and have emergency medications and equipment readily available. Monitoring for signs and symptoms of worsening preeclampsia and impending seizures is crucial for the client's safety and well-being.
The nurse is monitoring a client with severe preeclampsia. What assessment finding indicates worsening condition?
- A. Proteinuria of +1.
- B. Respiratory rate of 16 breaths per minute.
- C. New-onset confusion and restlessness.
- D. Urine output of 40 mL/hr.
Correct Answer: C
Rationale: New-onset confusion and restlessness may indicate cerebral edema or impending eclampsia.