Nokea
The doctor has ordered an IV of magnesium sulfate for a G1 P0 with preeclampsia. Which of the following symptoms is an expected side effect of magnesium sulfate?
- A. Oliguria
- B. Hypersomnolence
- C. Hyporeflexia
- D. Bradypnea
Correct Answer: C
Rationale: Hyporeflexia is an expected side effect of magnesium sulfate, used to monitor for toxicity in preeclampsia treatment.
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The nurse is talking with a client who has human immunodeficiency virus (HIV). Which of the following statements by the client would indicate a correct understanding of the condition? Select all that apply.
- A. I should receive the influenza vaccine every year
- B. I will ask my roommate to clean the cat litter box for me
- C. I should ask for my steak to be cooked thoroughly with no pink inside
- D. I can eat the raw vegetables I grew in my garden if my HIV viral load is undetectable
- E. I will use bottled water when brushing my teeth if I travel to an area with poor sanitation
Correct Answer: A,B,C,E
Rationale: Flu vaccine, avoiding cat litter (toxoplasmosis risk), thorough cooking, and bottled water in unsanitary areas reduce infection risk in HIV. Raw vegetables pose a risk, even with undetectable viral load.
The nurse is caring for a client with Parkinson's disease. The client spends over 1 hour to dress for scheduled therapies. What is the most appropriate action for the nurse to take in this situation?
- A. Ask family members to dress the client
- B. Encourage the client to dress more quickly
- C. Allow the client the time needed to dress
- D. Demonstrate methods on how to dress more quickly
Correct Answer: C
Rationale: Allow the client the time needed to dress. Clients with Parkinson's disease often wish to take care of themselves but become very upset when hurried and then are unable to manage at all.
A 2-year-old at an outpatient clinic stops breathing and does not have a pulse. CPR is initiated. When the automated external defibrillator (AED) arrives, the nurse notes that it has only adult AED pads. What is the appropriate action at this time?
- A. Continue CPR without using the automated external defibrillator (AED) until paramedics arrive
- B. Place one AED pad on the chest and the other on the back
- C. Place one AED pad on the upper right chest and the other on the lower left side
- D. Place one AED pad on the upper right chest and dispose of the other
Correct Answer: B
Rationale: For a 2-year-old, adult AED pads can be used by placing one on the chest and one on the back to accommodate smaller anatomy. Continuing CPR without AED delays defibrillation, and other options are incorrect pad placements.
The nurse is reinforcing information for a client with chronic obstructive pulmonary disease. Which statements by the client indicate an understanding of the pursed-lip breathing technique? Select all that apply.
- A. I exhale for 2 seconds through pursed lips
- B. I exhale for 4 seconds through pursed lips
- C. I inhale for 2 seconds through my mouth
- D. I inhale for 2 seconds through my nose, keeping my mouth closed
- E. I inhale for 4 seconds through my nose, keeping my mouth closed
Correct Answer: B,D
Rationale: Pursed-lip breathing involves inhaling 2 seconds through the nose (mouth closed) and exhaling 4 seconds through pursed lips to prolong exhalation and reduce air trapping in COPD.
The nurse is collecting data from a client with Bell’s palsy. Which of the following findings would the nurse expect to observe? Select all that apply.
- A. Inability to smile symmetrically
- B. Frequent blinking of the affected eye
- C. Shock-like pain in the lips and gums
- D. Loss of forehead and brow movements
- E. Decreased lacrimation on the affected side
Correct Answer: A,D,E
Rationale: Bell’s palsy causes unilateral facial weakness, leading to asymmetrical smiling, loss of forehead/brow movement, and reduced lacrimation. Frequent blinking is unlikely due to impaired muscle control, and shock-like pain is typical of trigeminal neuralgia.