Nokea
The lab reports a lecithin/sphingomyelin (L/S) ratio of 3:1 for a client who has been on bedrest 48 hours in an unsuccessful attempt to arrest premature labor at 33-weeks gestation. Based on this result, the nurse would anticipate
- A. administration of ritodrine hydrochloride (Yutopar).
- B. initiation of an oxytocin (Pitocin) drip.
- C. delivery of the infant by cesarean section.
- D. continuation of bedrest until otherwise indicated.
Correct Answer: C
Rationale: because the lungs are adequately mature, there is no need to attempt to postpone labor; delivery by cesarean section is generally preferred for preterm infants
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A patient is returned to his room following an appendectomy. The nurse notices a large amount of serosanguineous drainage on the dressing. It is MOST important for the nurse to obtain an answer to which of the following questions?
- A. Were there any intraoperative complications?
- B. Has the dressing been changed?
- C. Why didn't the recovery room nurse report any drainage?
- D. Was a tissue drain placed during surgery?
Correct Answer: D
Rationale: drain is frequently placed during surgery to prevent accumulation in wound, dressing should be reinforced
A middle-aged adult is seen in the emergency room for complaints of severe right-flank pain. The client is twenty pounds overweight, lives a sedentary lifestyle, and was treated for renal calculi four years ago. Which of the following actions, if performed by the nurse, is MOST important?
- A. Ensure that the client has nothing to eat or drink.
- B. Obtain a 'clean-catch' urine specimen for analysis.
- C. Provide warm packs to relieve discomfort.
- D. Measure and strain the client's urine.
Correct Answer: D
Rationale: will document passage of stone and allow composition to be analyzed
The mother of a seven-year-old child is dying.
The nurse should anticipate that the seven-year-old child would have which of the following concepts of death?
- A. Death is punishment for his/her actions.
- B. Death is inevitable and irreversible.
- C. Death is temporary and gradual.
- D. Death as a concept based on past experience.
Correct Answer: A
Rationale: Strategy: Remember growth and development. (1) correct-seven-year-olds see death as a punishment (2) by age of 9, most children begin to develop an adult concept of death and begin to understand that death is irreversible (3) is a preschool child's concept of death (4) is an adolescent's concept of death
A client is scheduled to have a parathyroidectomy. The nurse would be MOST concerned if the client was observed eating quantities of food from which of the following food groups?
- A. Milk products.
- B. Green vegetables.
- C. Seafood.
- D. Poultry products.
Correct Answer: A
Rationale: low-calcium diet is recommended preoperatively
The nurse is assessing a pregnant client with problems of mitral stenosis and congestive heart failure (CHF). Which of the following in the client's history would have a direct correlation with her current problem?
- A. History of rheumatic fever four years ago.
- B. Presence of ventricular septal defect as an infant.
- C. Heart disease in both the maternal and the paternal families.
- D. Persistent ear infections and mastoiditis as a child.
Correct Answer: A
Rationale: most common cause of mitral valve problems is a history of rheumatic fever with a subsequent complication of carditis, which affects the valve