Nokea
The client is admitted with a diagnosis of gestational diabetes. Which intervention is most appropriate?
- A. Monitor blood glucose levels
- B. Administer tocolytics
- C. Monitor fetal heart tones
- D. All of the above
Correct Answer: D
Rationale: Gestational diabetes requires blood glucose monitoring to maintain control fetal heart tone monitoring to assess fetal well-being and potentially other interventions. Tocolytics are not indicated unless preterm labor occurs.
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A client with a history of Cushing’s syndrome is admitted with complaints of weight gain. The nurse should expect the client to have:
- A. Moon face
- B. Weight loss
- C. Hypotension
- D. Bradycardia
Correct Answer: A
Rationale: Cushing’s syndrome causes excess cortisol, leading to moon face, central obesity, and weight gain.
At 30 weeks' gestation, a client is admitted to the unit in premature labor. Her contractions are every 5 minutes and last 60 seconds, her cervix is closed, and the suture placed around her cervix during her 16th week of gestation, when she had the MacDonald procedure, can still be felt by the physician. The amniotic sac is still intact. She is very concerned about delivering prematurely. She asks the RN, 'What is the greatest risk to my baby if it is born prematurely?' The RN's answer should be:
- A. Hyperglycemia
- B. Hypoglycemia
- C. Lack of development of the intestines
- D. Lack of development of the lungs
Correct Answer: D
Rationale: Any infant would be at risk for hyperglycemia because the infant's liver is missing the islets of Langerhans, which secrete insulin to break down glucose for cellular use. Prematurity is not an added risk for hyperglycemia. Both premature and mature infants can be at risk for hypoglycemia if their mother had gestational diabetes during pregnancy or entered the pregnancy with diabetes mellitus. These infants are exposed to high levels of maternal glucose while in utero, which causes the islets of Langerhans in the infant's liver to produce insulin. After birth when the umbilical cord is severed, the generous amount of maternal blood glucose is eliminated; however, there is continued islet cell hyperactivity in the infant's liver, which can lead to excessive insulin levels and depleted blood glucose. Mature infants are born with an immature GI system. The nervous control of the stomach is incomplete at birth, salivary glands are immature at birth, and the intestinal tract is sterile. This is not the greatest risk to a premature infant. The greatest risk to a premature infant is the lack of development of the lungs, which can lead to respiratory distress syndrome due to insufficient surfactant production.
The elderly client is being discharged following a total knee replacement. To facilitate independence, the nurse should instruct the client/family to do which of the following?
- A. Use an elevated commode seat.
- B. Remove throw rugs from the floor.
- C. Install grab bars in the bathroom.
- D. Wear a medic alert monitor.
- E. Leave the nightlight on during resting hours.
- F. Apply foot protectors to the heels.
- G. Place the walker at the bedside.
Correct Answer: A, B, C, D, E, G
Rationale: Elevated commode seats (A), removing rugs (B), grab bars (C), medic alert monitors (D), nightlights (E), and bedside walkers (G) promote safety and independence. Foot protectors (F) are unrelated to mobility, and elevated side rails (H) may trap the client, increasing fall risk.
A 70-year-old homeless woman is admitted with pneumonia. She is weak, emaciated, and febrile. The physician orders enteral feedings intermittently by nasogastric tube. When inserting the nasogastric tube, once the tube passes through the oropharynx, the nurse will instruct the client to:
- A. Tilt her head backwards
- B. Swallow as tube passes
- C. Hold breath as tube passes
- D. Cough as tube passes
Correct Answer: B
Rationale: Swallowing assists with insertion of tube and closes off airway.
Azulfidine (Sulfasalazine) may be ordered for a client who has ulcerative colitis. Which of the following is a nursing implication for this drug?
- A. Limit fluids to 500 mL/day.
- B. Administer 2 hours before meals.
- C. Observe for skin rash and diarrhea.
- D. Monitor blood pressure, pulse.
Correct Answer: C
Rationale: Sulfasalazine commonly causes skin rash and diarrhea, which should be monitored. The other options are not relevant nursing implications.