Nokea
Marie is a 38-year-old primigravida who is admitted with a diagnosis of pregnancy induced hypertension (PIH).
Priority nursing care on the patient with PIH include:
- A. Urinary protein, 2 grams/24hous.
- B. HR 110 bpm.
- C. Urine output 335 ml/24 hours.
- D. Patellar reflex positive.
Correct Answer: C
Rationale: Low urine output (335 ml/24 hours) indicates possible renal involvement in PIH, a priority for monitoring and reporting to prevent further complications.
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B.C. is a 14-yr-old boy who was brought to the ER after he had sustained flame burns. He had been wearing masquerade costume during Halloween celebration when his costume was set ablaze by the lighted candles in the party room. He extinguished the fire by rolling on the floor. On admission, resuscitation was commenced with intravenous fluids, antibiotics, and wound dressing. On examination he was found to be a young man, not pale, but febrile (body temperature, 37.8°C). He was tachypneic, RR 26 per min, with audible breath sounds bilaterally. Burn assessment revealed a total body surface area involved of 30%, with mixed-thickness burns sparing some patchy areas of the back and the right upper limb. B.C. anterior chest was affected.
For the first 24 hours after hospitalization, the nurse should primarily observe him for
- A. wound sepsis.
- B. complain of pain.
- C. dyspnea or stridor.
- D. initiate IV therapy.
Correct Answer: C
Rationale: Inhalation burns are usually present with facial burns, regardless of the depth; the immediate threat to life is asphyxia from irritation and edema of the respiratory passages and lungs.
A client on warfarin therapy following coronary artery stent placement calls the clinic to ask if he can take Alka-Seltzer for an upset stomach. What is the best response by the nurse?
- A. Avoid Alka-Seltzer because it contains aspirin
- B. Take Alka-Seltzer at a different time of day than the warfarin
- C. Select an antacid that does not interact with warfarin
- D. Use one-half the recommended dose of Alka-Seltzer
Correct Answer: A
Rationale: Avoid Alka-Seltzer because it contains aspirin. Alka-Seltzer is an over-the-counter aspirin-antacid combination. Aspirin, an antiplatelet drug, will potentiate the anticoagulant effect of warfarin, which may result in excess bleeding.
The nurse is caring for a client with a fractured femur who is in skeletal traction. Which of the following actions is MOST important for the nurse to perform?
- A. Check the pin sites for signs of infection.
- B. Ensure the weights are hanging freely.
- C. Perform range-of-motion exercises on the affected leg.
- D. Reposition the client every 4 hours.
Correct Answer: B
Rationale: Ensuring weights hang freely maintains proper traction alignment, preventing complications like malunion. Checking pin sites (A) is important but secondary, ROM exercises (C) are contraindicated in traction, and repositioning (D) is limited to maintain traction.
A client has been on antibiotics for 72 hours for cystitis. Which report from the client requires priority attention by the nurse?
- A. foul smelling urine
- B. burning on urination
- C. elevated temperature
- D. nausea and anorexia
Correct Answer: C
Rationale: Elevated temperature after 72 hours on an antibiotic indicates the antibiotic has not been effective in eradicating the offending organism. The provider should be informed immediately so that an appropriate medication can be prescribed, and complications such as pyelonephritis are prevented.
Which of the following is the primary force in sex education in a child's life?
- A. school nurse
- B. peers
- C. parents
- D. media
Correct Answer: C
Rationale: Parents are the primary influence on a child's sex education, providing foundational values and information. Other sources like peers and media are influential but secondary. Health Promotion and Maintenance