Nokea
The client is admitted with a diagnosis of chorioamnionitis. Which vital sign change is most likely to be observed?
- A. Maternal fever
- B. Tachycardia
- C. Fetal bradycardia
- D. All of the above
Correct Answer: D
Rationale: Chorioamnionitis causes maternal fever (from infection) tachycardia (from systemic response) and fetal bradycardia (from distress). All vital sign changes are likely in this condition.
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To ensure proper client education, the nurse should teach the client taking SL nitroglycerin to expect which of the following responses with administration?
- A. Stinging, burning when placed under the tongue
- B. Temporary blurring of vision
- C. Generalized urticaria with prolonged use
- D. Urinary frequency
Correct Answer: A
Rationale: Stinging or burning when nitroglycerin is placed under the tongue is to be expected. This effect indicates that the medication is potent and effective for use. Failure to have this response means that the client needs to get a new bottle of nitroglycerin. (B, C, D) The other responses are not expected in this situation and are not even side effects.
A client with a history of heart failure is receiving Spironolactone (Aldactone). The nurse should teach the client to:
- A. Avoid potassium-rich foods
- B. Increase sodium intake
- C. Take the medication at bedtime
- D. Limit fluid intake
Correct Answer: A
Rationale: Spironolactone, a potassium-sparing diuretic, risks hyperkalemia, so potassium-rich foods should be avoided. Sodium restriction, daytime dosing, and fluid management are secondary.
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 female client who has chronic obstructive pulmonary disease (COPD) has presented in the emergency department with cough productive of yellow sputum and increasing shortness of breath. On room air, her blood gases are as follows: pH 7.30 mm Hg, PCO2 60 mm Hg, PO2 55 mm Hg, HCO3 32 mEq/L. These arterial blood gases reflect:
- A. Compensated respiratory acidosis
- B. Normal blood gases
- C. Uncompensated metabolic acidosis
- D. Uncompensated respiratory acidosis
Correct Answer: D
Rationale: Low pH, high PCO2, and normal HCO3 indicate uncompensated respiratory acidosis, reflecting acute exacerbation of COPD.
The nurse is caring for a client with a history of a hysterectomy. The client complains of hot flashes. The nurse should:
- A. Apply a heating pad
- B. Encourage fluid restriction
- C. Discuss hormone replacement therapy
- D. Administer acetaminophen
Correct Answer: C
Rationale: Hot flashes post-hysterectomy are due to hormonal changes. Discussing hormone replacement therapy with the physician is appropriate. Heating pads, fluid restriction, and acetaminophen are ineffective.