Nokea
The client at 35 weeks gestation is admitted with a diagnosis of vasa previa. The nurse should monitor for which complication?
- A. Fetal bleeding
- B. Maternal hemorrhage
- C. Preterm labor
- D. Fetal macrosomia
Correct Answer: A
Rationale: Vasa previa involves fetal blood vessels crossing the cervical os risking rupture and fetal bleeding during labor or membrane rupture. Maternal hemorrhage preterm labor and macrosomia are less directly related.
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The nurse is observing a student gauss administering ear drops to a two-year-old. Which observation by the nurse would indicate correct technique?
- A. Holds the child's head up and extended
- B. Places the head in chin-tuck position
- C. Pulls the pinna down and back
- D. Irrigates the ear before administering medication
Correct Answer: C
Rationale: Pulling the pinna down and back in children straightens the ear canal for proper ear drop administration. Head extension (A), chin-tuck (B), and irrigation (D) are incorrect.
The client is prescribed ipratropium (Atrovent) and albuterol (Proventil) via inhaler. Which instruction should the nurse include?
- A. Use albuterol first, then ipratropium.'
- B. Use ipratropium first, then albuterol.'
- C. Use both inhalers simultaneously.'
- D. Use only one inhaler per day.'
Correct Answer: A
Rationale: Albuterol, a bronchodilator, is used first to open airways, followed by ipratropium, an anticholinergic, to maintain bronchodilation. Simultaneous or single daily use is incorrect.
The nurse is caring for a client with a history of a myocardial infarction who is receiving Nitroglycerin. The nurse should monitor the client for:
- A. Hypotension
- B. Tachycardia
- C. Hyperglycemia
- D. Fever
Correct Answer: A
Rationale: Nitroglycerin, a vasodilator, commonly causes hypotension due to decreased preload. Tachycardia is possible but secondary, and hyperglycemia/fever are unrelated.
The nurse has performed nutritional teaching on a client with gout who is placed on a low-purine diet. Which selection by the client would indicate that teaching has been ineffective?
- A. Boiled cabbage
- B. Apple
- C. Peach cobbler
- D. Spinach
Correct Answer: D
Rationale: Spinach is high in purines, which exacerbate gout. Selecting spinach indicates ineffective teaching. Cabbage (A), apple (B), and peach cobbler (C) are low-purine and appropriate.
A client with a history of alcoholism is admitted with a diagnosis of cirrhosis. The nurse can expect the client to exhibit:
- A. Lower extremity edema
- B. Dilated pupils
- C. Warm, dry skin
- D. Bradycardia
Correct Answer: A
Rationale: Cirrhosis impairs liver function, leading to portal hypertension and hypoalbuminemia, causing lower extremity edema. Dilated pupils, warm skin, and bradycardia are not typical.