Nokea
The client is admitted with a diagnosis of postpartum depression. Which vital sign change is most likely to be observed?
- A. Normal vital signs
- B. Fever
- C. Tachycardia
- D. Hypotension
Correct Answer: A
Rationale: Postpartum depression is a psychological condition and typically does not cause vital sign changes. Fever tachycardia or hypotension suggest physical conditions like infection or hemorrhage.
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The doctor has ordered antithrombotic stockings to be applied to the legs of a client with peripheral vascular disease. The nurse knows antithrombotic stockings should be applied:
- A. Before the client arises in the morning
- B. With the client in a standing position
- C. After the client has bathed and applied lotion to the legs
- D. Before the client retires in the evening
Correct Answer: A
Rationale: Antithrombotic stockings should be applied before the client arises in the morning when edema is minimal, ensuring proper fit and maximum compression to promote venous return. Applying them later or after lotion can reduce effectiveness or cause skin irritation.
The nurse is caring for a client who is receiving terbutaline for preterm labor. Which side effect should the nurse monitor for?
- A. Maternal bradycardia
- B. Fetal hypoglycemia
- C. Maternal tachycardia
- D. Fetal macrosomia
Correct Answer: C
Rationale: Terbutaline a beta-agonist tocolytic commonly causes maternal tachycardia due to its stimulatory effects on the cardiovascular system. Maternal bradycardia fetal hypoglycemia and macrosomia are not associated side effects.
The client is diagnosed with a urinary tract infection. Which instruction should the nurse include in the discharge teaching?
- A. Limit fluid intake to reduce bladder irritation.'
- B. Take all prescribed antibiotics as directed.'
- C. Avoid sexual activity permanently.'
- D. Use heating pads to relieve discomfort.'
Correct Answer: B
Rationale: Completing the full course of antibiotics is essential to eradicate the infection and prevent resistance in a urinary tract infection. Fluid intake should increase, sexual activity can resume after treatment, and heating pads may not be advised.
A client with inflammatory bowel disease (IBD) requires an ileostomy. The nurse would instruct the client to do which of the following measures as an essential part of caring for the stoma?
- A. Perform massage of the stoma three times a day.
- B. Include high-fiber foods in the diet, especially nuts.
- C. Limit fluid intake to prevent loose stools.
- D. Cleanse the peristomal skin meticulously.
Correct Answer: D
Rationale: Meticulous cleansing of the peristomal skin prevents irritation and infection, essential for ileostomy care. Stoma massage (A) is unnecessary, high-fiber foods like nuts (B) may cause blockages, and limiting fluids (C) risks dehydration.
MgSO4 is ordered IV following the established protocol for a client with severe PIH. The anticipated effects of this therapy are anticonvulsant and:
- A. Vasoconstrictive
- B. Vasodilative
- C. Hypertensive
- D. Antiemetic
Correct Answer: B
Rationale: An anticonvulsant effect is the goal of drug therapy for PIH. However, we would not want to increase the vasoconstriction that is already present. This would make the symptoms more severe. An anticonvulsant effect and vasodilation are the desired outcomes when administering this drug. An anticonvulsant effect is the goal of drug therapy for PIH; however, hypertensive drugs would increase the blood pressure even more. An anticonvulsant effect is the goal of drug therapy for PIH. MgSO4 is not classified as an antiemetic. Antiemetics are not indicated for PIH treatment.