Nokea
The client at 30 weeks gestation is admitted with preterm labor. The physician orders indomethacin. The nurse should monitor for which side effect?
- A. Maternal hypertension
- B. Fetal bradycardia
- C. Oligohydramnios
- D. Maternal hypoglycemia
Correct Answer: C
Rationale: Indomethacin a tocolytic can reduce fetal urine output leading to oligohydramnios (low amniotic fluid). Maternal hypertension fetal bradycardia and hypoglycemia are not common side effects of indomethacin.
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The nurse is evaluating teaching effectiveness on a client with a gastrointestinal disorder prescribed a gluten-free diet. Which diet choice indicates that the client understands the instructions given?
- A. Steamed broccoli
- B. Wheat toast
- C. Chocolate chip cookie
- D. Bran cereal
Correct Answer: A
Rationale: Steamed broccoli is naturally gluten-free, indicating understanding of a gluten-free diet. Wheat toast (B), chocolate chip cookies (C), and bran cereal (D) contain gluten.
A client with increased intracranial pressure is receiving Osmitrol (Mannitol) and Furosemide (Lasix). The nurse recognizes that these two drugs are given to reverse which effect?
- A. Energy failure
- B. Excessive intracellular calcium
- C. Cellular edema
- D. Excessive glutamate release
Correct Answer: C
Rationale: Mannitol and Furosemide reduce cellular edema by promoting diuresis and osmotic fluid shifts, lowering ICP. Energy failure (A), calcium (B), and glutamate (D) are not directly targeted.
The nurse is caring for a client following a myocardial infarction. Which of the following enzymes are specific to cardiac damage?
- A. SGOT and LDH
- B. SGOT and CK BB
- C. LDH and CK MB
- D. LDH and CK BB
Correct Answer: C
Rationale: CK-MB and LDH are specific to cardiac damage, with CK-MB being highly specific for myocardial infarction due to its presence in heart muscle.
Which action by the healthcare worker indicates a need for further teaching?
- A. The nursing assistant ambulates the elderly client using a gait belt.
- B. The nurse wears goggles while performing a venipuncture.
- C. The nurse washes his hands after changing a dressing.
- D. The nurse wears gloves to monitor the IV infusion rate.
Correct Answer: D
Rationale: Wearing gloves to monitor an IV infusion rate is unnecessary unless contact with bodily fluids is anticipated indicating a need for further teaching on standard precautions. The other actions are appropriate safety measures.
A male client has been an insulin-dependent diabetic for approximately 30 years. He frequently indulges in high-sugar foods and forgets to take his insulin. He has not experienced acute diabetic emergencies over the years but is now beginning to demonstrate symptoms of diabetic peripheral neuropathy. This distresses him because dancing is one of his favorite pastimes. He decides to question his wife's home health nurse about diabetic peripheral neuropathy. The nurse points out his noncompliance to his diabetic diet and insulin regimen. The client answers the nurse, 'It has been my experience that the diabetic diet is very difficult to follow. As far as the insulin, isn't a fellow allowed to forget now and then?' The client's actions and response best demonstrate:
- A. Depression
- B. Anger
- C. Denial
- D. Bargaining
Correct Answer: C
Rationale: Depression may be an underlying feature, but it is not evident from limited data presented here. Anger is not exhibited in his response. Denial is evident in the client's actions; through the years, he has had a casual approach to his illness. He only becomes concerned when bodily changes affect his present lifestyle, when in fact he should have been concerned all along. His verbal response also reflects denial. There is no evidence of bargaining in the client's actions or verbal response.