Nokea
The client with preeclampsia is admitted to the unit with an order for magnesium sulfate IV. Which action by the nurse indicates a lack of understanding of magnesium sulfate?
- A. The nurse places a sign over the bed not to check blood pressures in the left arm.
- B. The nurse obtains an IV controller.
- C. The nurse inserts a Foley catheter.
- D. The nurse darkens the room.
Correct Answer: A
Rationale: Avoiding blood pressure checks in one arm is unrelated to magnesium sulfate; the other actions align with monitoring and managing side effects.
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The nurse is evaluating the intake and output of a client for the first 12 hours following an abdominal cholecystectomy. Which finding should be reported to the physician?
- A. Output of 10 mL from the Jackson-Pratt drain
- B. Foley catheter output of 285 mL
- C. Nasogastric tube output of 150 mL
- D. Absence of stool
Correct Answer: D
Rationale: Absence of stool post-cholecystectomy may indicate a complication like ileus or obstruction, requiring physician evaluation.
A client with cystic fibrosis is taking pancreatic enzymes. The nurse should administer this medication:
- A. Once per day in the morning
- B. Three times per day with meals
- C. Once per day at bedtime
- D. Four times per day
Correct Answer: B
Rationale: Pancreatic enzymes are taken with meals to aid digestion, as cystic fibrosis impairs pancreatic enzyme production.
The nurse is assessing the client recently returned from surgery. The nurse is aware that the best way to assess pain is to:
- A. Take the blood pressure, pulse, and temperature
- B. Ask the client to rate his pain on a scale of 0-5
- C. Watch the client's facial expression
- D. Ask the client if he is in pain
Correct Answer: B
Rationale: A pain scale provides a reliable, subjective measure of pain.
The nurse is performing an assessment of an elderly client with a total hip repair. Based on this assessment, the nurse decides to medicate the client with an analgesic. Which finding most likely prompted the nurse to decide to administer the analgesic?
- A. The client's blood pressure is 130/86.
- B. The client is unable to concentrate.
- C. The client's pupils are dilated.
- D. The client grimaces during care.
Correct Answer: D
Rationale: Grimacing during care indicates pain, prompting the nurse to administer an analgesic.
The mother of a child with chickenpox wants to know if there is a medication that will shorten the course of the illness. Which medication is sometimes used to speed healing of the lesions and shorten the duration of fever and itching?
- A. Zovirax (acyclovir)
- B. Varivax (varicella vaccine)
- C. VZIG (varicella-zoster immune globulin)
- D. Periactin (cyproheptadine)
Correct Answer: A
Rationale: Acyclovir can reduce the severity and duration of chickenpox symptoms if started early, particularly in high-risk patients.