Nokea
The client at 34 weeks gestation is admitted with a diagnosis of gestational hypertension. Which assessment finding requires immediate intervention?
- A. Blood pressure of 150/100
- B. 2+ proteinuria
- C. Absence of deep tendon reflexes
- D. Edema of the lower extremities
Correct Answer: C
Rationale: Absence of deep tendon reflexes in gestational hypertension suggests magnesium toxicity (if receiving magnesium sulfate) or severe neurological complications requiring immediate intervention. The other findings while concerning are less urgent.
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The client is receiving a continuous heparin infusion. Which laboratory value should the nurse monitor most closely?
- A. Platelet count
- B. Prothrombin time (PT)
- C. Activated partial thromboplastin time (aPTT)
- D. International normalized ratio (INR)
Correct Answer: C
Rationale: Heparin’s anticoagulant effect is monitored by aPTT, with a therapeutic range of 1.5–2.5 times the control value. Platelet count is monitored for heparin-induced thrombocytopenia, but PT and INR are for warfarin.
The client is admitted with a diagnosis of postpartum endometritis. Which symptom is most likely to be present?
- A. Foul-smelling lochia
- B. Painless vaginal bleeding
- C. Decreased uterine tenderness
- D. Fetal distress
Correct Answer: A
Rationale: Postpartum endometritis a uterine infection typically causes foul-smelling lochia due to bacterial infection. Painful uterine tenderness is common painless bleeding suggests other causes and fetal distress is irrelevant postpartum.
A client with BPH has undergone a TURP. Which nursing interventions are parts of the client's post-operative care?
- A. Monitoring the client's vital signs
- B. Maintaining constant bladder irrigation
- C. Limiting fluid intake to 1000 mL per day
- D. Checking for post-operative bleeding
- E. Maintaining bed rest for 48 hours
Correct Answer: A, B, D
Rationale: Post-TURP care includes monitoring vital signs (A), constant bladder irrigation (B) to prevent clots, and checking for bleeding (D). Fluid intake is encouraged (C), and bed rest is typically 24 hours (E).
The nurse discovers that a 78-year-old client who received hydralazine (Apresoline) 20 mg 45 minutes ago has a blood pressure of 70/40 mm Hg. The client has been on this dose of the medication for 3 years. Which of the following data is most likely significant in relation to the cause of the low blood pressure?
- A. Pedal pulses 11 (weak)
- B. Twenty-four-hour intake 1000 mL/day for past 2 days
- C. Serum potassium 3.3
- D. Pulse rate 150 bpm
Correct Answer: B
Rationale: (A, D) Decreased pulse volume and increased pulse rate are signs of an acute hypotensive episode. Inadequate fluid volume when taking vasodilators can result in a drop in blood pressure when vasodilation starts to physiologically occur as an action of the drug. A potassium level of 3.3 would not be associated with a significant drop in blood pressure.
As soon as a child has been diagnosed as 'hearing impaired,' special education should begin. Which of the following special education tasks is the most difficult for a severely hearing-impaired child?
- A. Auditory training
- B. Speech
- C. Lip reading
- D. Signing
Correct Answer: B
Rationale: With the slight and mild hard of hearing, auditory training is beneficial. Speech is the most difficult task because it is learned by visual and auditory stimulation, imitation, and reinforcement. (C, D) Lip reading and signing are aimed at establishing communicative skills, but they are learned more easily by visual stimulation.