Nokea
The client taking Glyburide (Diabeta) should be cautioned to:
- A. Avoid eating sweets
- B. Report changes in urinary pattern
- C. Allow 3 hours for onset
- D. Check the glucose daily
Correct Answer: D
Rationale: Daily glucose monitoring is essential for clients on Glyburide to manage blood sugar levels effectively.
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The client is having fetal heart rates of 100-110 beats per minute during the contractions. The first action the nurse should take is to:
- A. Apply an internal monitor
- B. Turn the client to her side
- C. Get the client up and walk her in the hall
- D. Move the client to the delivery room
Correct Answer: B
Rationale: Turning the client to her side improves uteroplacental perfusion, addressing fetal bradycardia during contractions.
A client who has glaucoma is to have miotic eyedrops instilled in both eyes. The nurse knows that the purpose of the medication is to:
- A. Anesthetize the cornea
- B. Dilate the pupils
- C. Constrict the pupils
- D. Paralyze the muscles of accommodation
Correct Answer: C
Rationale: Miotics constrict the pupils, increasing aqueous humor outflow to reduce intraocular pressure in glaucoma.
The infant is admitted to the unit with Tetralogy of Fallot. The nurse would anticipate an order for which medication?
- A. Digoxin
- B. Epinephrine
- C. Aminophyline
- D. Atropine
Correct Answer: A
Rationale: Digoxin is commonly used in Tetralogy of Fallot to improve cardiac function and manage heart failure symptoms.
Which obstetrical client is most likely to have an infant with respiratory distress syndrome?
- A. A 28-year-old with a history of alcohol use during the pregnancy
- B. A 24-year-old with a history of diabetes mellitus
- C. A 30-year-old with a history of smoking during the pregnancy
- D. A 32-year-old with a history of pregnancy-induced hypertension
Correct Answer: B
Rationale: Maternal diabetes increases the risk of respiratory distress syndrome in infants due to impaired surfactant production from fetal hyperglycemia.
The nurse is preparing to suction the client with a tracheotomy. The nurse notes a previously used bottle of normal saline on the client's bedside table. There is no label to indicate the date or time of initial use. The nurse should:
- A. Lip the bottle and use a pack of sterile 4x4 for the dressing
- B. Obtain a new bottle and label it with the date and time of first use
- C. Ask the ward secretary when the solution was requested
- D. Label the existing bottle with the current date and time
Correct Answer: B
Rationale: Using an unlabeled, previously opened saline bottle risks contamination; a new, labeled bottle ensures sterility.