Nokea
The client is admitted with a diagnosis of preterm labor. Which intervention is most appropriate?
- A. Administer betamethasone
- B. Monitor fetal heart tones
- C. Administer tocolytics
- D. All of the above
Correct Answer: D
Rationale: In preterm labor betamethasone enhances fetal lung maturity tocolytics (e.g. nifedipine) halt contractions and fetal heart tone monitoring assesses fetal well-being. All interventions are appropriate.
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The nurse is caring for a client with a history of a pneumothorax who has a chest tube in place. The nurse should:
- A. Clamp the chest tube during transport
- B. Strip the chest tube every hour
- C. Keep the drainage system below chest level
- D. Empty the drainage system daily
Correct Answer: C
Rationale: Keeping the drainage system below chest level prevents fluid backflow into the chest. Clamping risks pneumothorax, stripping is outdated, and emptying is per protocol, not daily.
The client is admitted with a diagnosis of gestational diabetes. Which dietary recommendation is most appropriate?
- A. Low-carbohydrate,high-protein diet
- B. High-fat,low-calorie diet
- C. Low-protein,high-carbohydrate diet
- D. High-calorie,low-fat diet
Correct Answer: A
Rationale: A low-carbohydrate high-protein diet helps maintain stable blood glucose levels in gestational diabetes reducing the risk of hyperglycemia. High-fat high-carbohydrate or high-calorie diets are less suitable.
The parents of a child with cystic fibrosis ask what determines the prognosis of the disease. The nurse knows that the greatest determinant of the prognosis is:
- A. The degree of pulmonary involvement
- B. The ability to maintain an ideal weight
Correct Answer: A
Rationale: Pulmonary involvement is the primary determinant of prognosis in cystic fibrosis, as progressive lung disease is the leading cause of morbidity and mortality.
A 35-year-old client is receiving psychopharmacological treatment of his major depression with tranylcypromine sulfate (Parnate), a monoamine oxidase (MAO) inhibitor. The nurse teaches the client that while he is taking this type of antidepressant, he needs to restrict his dietary intake of:
- A. Potassium-rich foods
- B. Tryptophan
- C. Tyramine
- D. Saturated fats
Correct Answer: C
Rationale: The client may need to avoid some potassium-rich foods (such as bananas, raisins, etc.). However, this is not because of the potassium content of these foods. Tryptophan is an essential amino acid that is present in high concentrations in animal and fish protein. The client will need to watch his dietary intake of tyramine. Tyramine is a by-product of the conversion of tyrosine to epinephrine. Tyramine is found in a variety of foods and beverages, ranging from aged cheese to caffeine drinks. Ingestion of tyramine-rich foods while taking a MAO inhibitor may lead to an increase in blood pressure and/or a life-threatening hypertensive crisis. To maintain a healthy lifestyle, restriction of dietary saturated fats is advisable.
A client hospitalized with cirrhosis has developed abdominal ascites. The nurse should provide the client with snacks that provide additional:
- A. Sodium
- B. Potassium
- C. Protein
- D. Fat
Correct Answer: C
Rationale: Ascites in cirrhosis is linked to hypoalbuminemia; increasing protein intake helps restore albumin levels, reducing fluid accumulation.