Nokea
The client is admitted with a diagnosis of preeclampsia. The nurse should monitor for which complication?
- A. Seizures
- B. Premature rupture of membranes
- C. Fetal macrosomia
- D. Maternal hypoglycemia
Correct Answer: A
Rationale: Preeclampsia can progress to eclampsia characterized by seizures a life-threatening complication. Premature rupture of membranes macrosomia and hypoglycemia are not directly related to preeclampsia.
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The client is receiving a blood transfusion. Which finding indicates a possible transfusion reaction?
- A. Temperature of 100.2°F
- B. Blood pressure of 110/70 mmHg
- C. Respiratory rate of 24 breaths per minute
- D. Itching and rash on the trunk
Correct Answer: D
Rationale: Itching and rash are signs of a possible allergic transfusion reaction, requiring immediate cessation of the transfusion. A slight temperature increase, mild hypotension, or tachypnea may occur but are less specific without other symptoms.
The physician has ordered Dilantin (phenytoin) 100 mg intravenously for a client with generalized tonic clonic seizures. The nurse should administer the medication:
- A. Rapidly with an IV push
- B. With IV dextrose
- C. Slowly over 2-3 minutes
- D. Through a small vein
Correct Answer: C
Rationale: Phenytoin must be administered slowly (over 2-3 minutes) to prevent cardiovascular complications like hypotension or arrhythmias. It should not be mixed with dextrose or given rapidly.
The nurse would teach a male JOB client ways to minimize the risk of infection after eye surgery. Which of the following indicates the client needs further teaching?
- A. I will wash my hands before instilling eye medications.'
- B. I will wear sunglasses when going outside.'
- C. I will wear an eye patch for the first 3 postoperative days.'
- D. I will maintain the sterility of the eye medications.'
Correct Answer: C
Rationale: Eye patches are typically worn during sleep or naps, not constantly for 3 days, indicating a need for further teaching. The other options are correct preventive measures.
A 71-year-old client fell and injured her left leg while cooking in the kitchen. Her husband calls the ambulance, and she is taken to the emergency department at a local hospital. X-ray reports confirm that she has an intertrochanteric fracture of the left femur. Her left leg will require skeletal traction initially and then surgery. The nurse knows that this type of traction will be used:
- A. By inserting pins to provide steady pull on the bone
- B. To suspend the leg in a sling without pull on the extremity
- C. Intermittently to place a pull over the pelvis and lower spine
- D. With weights at both ends of the bed to maintain pull on the upper extremity
Correct Answer: A
Rationale: Skeletal traction is the application of traction directly to bone with the use of pins and wires or tongs for the purpose of providing a strong, steady, continuous longitudinal pull on the bone. It is indicated for preoperative immobilization and positioning of hip and femur fractures. A type of skeletal traction (balanced suspension with a Thomas splint and Pearson attachment) uses a sling to support the extremity, but it also uses weights to provide a strong, steady continuous pull on the extremity. A sling is used instead of pins. Pelvic traction provides an intermittent pull over the pelvis and bone, whereas skeletal traction is continuous. Pelvic traction does not use pins. Skeletal traction uses weights at the end of the bed to provide a continuous pull on long bones. Weights are not applied to both ends of the bed.
The nurse observes a client crying quietly. She has just experienced a spontaneous abortion at nine weeks' gestation. An appropriate response by the nurse would be:
- A. It must be God's will and probably is for the best.'
- B. This must be a difficult time for you. Would you like to talk about it?'
- C. I'm sure your other children will be a comfort for you.'
- D. Don't worry, you're still young. If I were you I'd just try again.'
Correct Answer: B
Rationale: This response is nontherapeutic because it belittles the client's response and gives a meaningless rationalization. This response acknowledges the client's feelings and demonstrates the therapeutic offering of self by the nurse. This response is nontherapeutic because it does not focus on the client's feelings and offers false reassurance. This response is nontherapeutic because it belittles the client's feelings and offers her advice.