Nokea
The client with a history of preterm labor is being monitored at 28 weeks gestation. The physician orders betamethasone (Celestone). The rationale for administering betamethasone is to:
- A. Prevent infection
- B. Stimulate labor
- C. Enhance fetal lung maturity
- D. Prevent bleeding
Correct Answer: C
Rationale: Betamethasone a corticosteroid is given to women in preterm labor (24-34 weeks) to enhance fetal lung maturity by promoting surfactant production reducing the risk of respiratory distress syndrome. It does not prevent infection stimulate labor or prevent bleeding.
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A client with a history of a stroke is being taught to use a quad cane. The nurse should teach the client to:
- A. Hold the cane in the strong hand
- B. Advance the cane with the strong leg
- C. Use the cane on the weak side
- D. Lean heavily on the cane
Correct Answer: C
Rationale: The quad cane should be used on the weak side to support the affected leg post-stroke, improving balance. Holding in the strong hand or advancing with the strong leg is incorrect.
The nurse asks a patient about current medications. Which one of the patient's medications is most likely to cause abdominal pain?
- A. Norco (hydrocodone/APAP)
- B. Erythrocin (erythromycin)
- C. Zyrtec (cetirizine)
- D. Aldactone (spironolactone)
Correct Answer: B
Rationale: Erythromycin commonly causes gastrointestinal side effects, including abdominal pain, due to its motility-stimulating effects. Norco may cause constipation, Zyrtec is less likely to affect the GI tract, and Aldactone’s side effects are primarily electrolyte-related.
The nurse is caring for a client with a history of hypothyroidism. The nurse should expect the client to have:
- A. Fatigue
- B. Tachycardia
- C. Weight loss
- D. Diarrhea
Correct Answer: A
Rationale: Hypothyroidism slows metabolism, causing fatigue, weight gain, and cold intolerance.
The nurse is caring for a client hospitalized with nephrotic syndrome. Based on the client's treatment, the nurse should:
- A. Limit the number of visitors.
- B. Provide a low-protein diet.
- C. Discuss the possibility of dialysis.
- D. Offer the client additional fluids.
Correct Answer: D
Rationale: Nephrotic syndrome causes edema due to protein loss, requiring fluid management. Offering additional fluids is inappropriate unless prescribed, as it may worsen edema. Visitors, diet, and dialysis depend on specific orders.
On assessment, the nurse learns that a chronic paranoid schizophrenic has been taking 'the blue pill' (haloperidol) in the morning and evening, and 'the white pill' (benztropine) right before bedtime. The nurse might suggest to the client that she try:
- A. Doubling the daily dose of benztropine
- B. Decreasing the haloperidol dosage for a few days
- C. Taking the benztropine in the morning
- D. Taking her medication with food or milk
Correct Answer: C
Rationale: Suggesting that a client increase a medication dosage is an inappropriate (and illegal) nursing action. This action requires a physician's order. To suggest that a client decrease a medication dosage is an inappropriate (and illegal) nursing action. This action requires a physician's order. This response is an appropriate independent nursing action. Because motor restlessness can also be a side effect of cogentin, the nurse may suggest that the client try taking the drug early in the day rather than at bedtime. Certain medications can cause gastric irritation and may be taken with food or milk to prevent this side effect.