Nokea
The client is admitted with a diagnosis of preterm labor. Which symptom is most characteristic?
- A. Uterine contractions
- B. Fetal macrosomia
- C. Maternal fever
- D. Painless vaginal bleeding
Correct Answer: A
Rationale: Uterine contractions (regular frequent) are the hallmark of preterm labor occurring before 37 weeks. Fetal macrosomia maternal fever and painless bleeding are not characteristic.
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The physician has ordered that ampicillin 250 mg IV be given over 30 minutes. The medication is diluted as recommended in 10 mL in the volume control chamber of a set that has a tubing of 12 mL. Which nursing measure is most accurate considering these facts?
- A. Infuse volume at 44 mL/hr.
- B. Infuse volume at 22 mL/hr.
- C. Infuse volume at 10 mL/hr.
- D. Infuse volume at 30 mL/hr.
Correct Answer: A
Rationale: The volume to be infused should be diluted medication volume added to the volume control chamber (10 mL) plus the tubing volume (12 mL). The general formula for calculating IV medications for children is: Rate = Volume to Be Infused X Administration Set Drop Factor (microdrop: 60 gtts/min) / Desired Time to Infuse in Minutes Rate = (10 + 12) 22 × 60 / 30 = 44 mL/hr. (B, C, D) These values are incorrect.
The client is having electroconvulsive therapy for treatment of severe depression. Prior to the ECT,the nurse should:
- A. Apply a tourniquet to the client's arm
- B. Administer an anticonvulsant medication
- C. Ask the client if he is allergic to shellfish
- D. Apply a blood pressure cuff to the arm
Correct Answer: D
Rationale: A blood pressure cuff is applied to one limb during ECT to monitor for seizure activity (visible in the uncuffed limb). Tourniquets anticonvulsants and shellfish allergies are not relevant to ECT preparation.
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 Clamping risks pneumothorax, stripping is outdated, and emptying is per protocol, not daily.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 nurse is teaching a client with a history of kidney stones about dietary modifications. The nurse should tell the client to:
- A. Increase fluid intake
- B. Avoid all calcium
- C. Consume high-oxalate foods
- D. Reduce protein intake
Correct Answer: A
Rationale: Increasing fluid intake dilutes urine, reducing the risk of kidney stone formation.
Which of the following physician's orders would the nurse question on a client with chronic arterial insufficiency?
- A. Neurovascular checks every 2 hours
- B. Elevate legs on pillows
- C. Arteriogram in the morning
- D. No smoking
Correct Answer: B
Rationale: Neurovascular checks are a routine part of assessment with clients having this diagnosis. Elevation of the legs is contraindicated because it reduces blood flow to areas already compromised. Arteriogram is a routine diagnostic order. Smoking is highly correlated with this disorder.