The nurse in the prenatal clinic is monitoring a client who is pregnant with twins. The nurse monitors the client closely for which priority complication that is associated with a twin pregnancy?
- A. Hemorrhoids
- B. Postterm labor
- C. Maternal anemia
- D. Costovertebral angle tenderness
Correct Answer: C
Rationale: Maternal anemia often occurs in twin pregnancies because of a greater demand for iron by the fetuses. Options 1 and 4 occur in a twin pregnancy but would not be as high a priority as anemia. Option 2 is incorrect because twin pregnancies often end in prematurity.
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The nurse evaluates a client after treatment for carbon monoxide poisoning following a burn injury. The nurse should document that the treatment was effective if which finding was present? Select all that apply.
- A. The client is sleeping soundly.
- B. The client is awake and talking.
- C. Respiratory rate is 26 breaths/minute.
- D. The client's heart rate is 84 beats/minute.
- E. Carboxyhemoglobin levels are less than 5%.
- F. The heart monitor shows normal sinus rhythm.
Correct Answer: D,E,F
Rationale: Normal carboxyhemoglobin levels are less than 5% for a nonsmoking adult. Clients can be awake and talking with abnormally high levels. The symptoms of carbon monoxide poisoning are tachycardia, tachypnea, and central nervous system depression.
Which medication instructions should the nurse provide to a client who has been prescribed levothyroxine? Select all that apply.
- A. Monitor your own pulse rate.
- B. Take the medication in the morning.
- C. Take the medication at the same time each day.
- D. Notify the primary health care provider if chest pain occurs.
- E. Expect the pulse rate to be greater than 100 beats per minute.
- F. It may take 1 to 3 weeks for a full therapeutic effect to occur.
Correct Answer: A,B,C,D,F
Rationale: Levothyroxine is a thyroid hormone. The client is instructed to monitor her or his own pulse rate. The client is also instructed to take the medication in the morning before breakfast to prevent insomnia and to take the medication at the same time each day to maintain hormone levels. The client is told not to discontinue the medication and that thyroid replacement is lifelong. Additional instructions include contacting the primary health care provider if the rate is greater than 100 beats per minute and notifying the primary health care provider if chest pain occurs, or if weight loss, nervousness and tremors, or insomnia develops. The client is also told that full therapeutic effect may take 1 to 3 weeks and that he or she needs to have follow-up thyroid blood studies to monitor therapy.
The nurse, while caring for a hospitalized infant being monitored for increased intracranial pressure (ICP), notes that the anterior fontanel bulges when the infant cries. Based on this assessment finding, which conclusion should the nurse draw?
- A. That no action is required.
- B. The head of the bed needs to be lowered.
- C. The infant needs to be placed on NPO status.
- D. The primary health care provider should be notified immediately.
Correct Answer: A
Rationale: A bulging anterior fontanel in an infant when crying is a normal finding, as crying increases intracranial pressure temporarily. This does not indicate a pathological condition requiring immediate intervention. Lowering the head of the bed or placing the infant on NPO status is not warranted, and notifying the primary health care provider is unnecessary unless other signs of increased ICP, such as persistent bulging at rest, irritability, or lethargy, are present.
The nurse is encouraging the client to cough and deep breathe after cardiac surgery. The nurse ensures that which item is available to maximize the effectiveness of this procedure?
- A. Nebulizer
- B. Ambu bag
- C. Suction equipment
- D. Incisional splinting pillow
Correct Answer: D
Rationale: The use of an incisional splint such as a 'cough pillow' can ease discomfort during coughing and deep breathing. The client who is comfortable will do more effective deep breathing and coughing exercises. Use of an incentive spirometer is also indicated. Options 1, 2, and 3 will not encourage the client to cough and deep breathe.
The nurse is caring for a client who has been placed in skin traction. Which action by the nurse provides for countertraction to reduce shear and friction?
- A. Using a footboard
- B. Providing an overhead trapeze
- C. Slightly elevating the foot of the bed
- D. Slightly elevating the head of the bed
Correct Answer: C
Rationale: The part of the bed under an area in traction is usually elevated to aid in countertraction. For the client in skin traction (which is applied to a leg), the foot of the bed is elevated. Option 3 provides a force that opposes the traction force effectively without harming the client. A footboard, an overhead trapeze, or elevating the head of the bed is not used to provide countertraction.