Nokea
The nurse is assisting with the care of a client who is scheduled to receive an oxytocin infusion to induce labor. The nurse should recognize that oxytocin infusion can lead to
- A. decreased risk for postpartum hemorrhage
- B. fetal distress and cesarean birth
- C. increased risk for placenta previa
- D. preeclampsia and hypernatremia
Correct Answer: B
Rationale: Oxytocin can cause uterine hyperstimulation, leading to fetal distress and potential cesarean delivery.
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The nurse is caring for a woman who is admitted for a hysterectomy. The woman does not speak English. No staff members speak the client's language. Which approach by the nurse would be most appropriate when communicating with the client about her care before and after the surgery?
- A. Ask the woman's 8-year-old daughter who speaks English to interpret.
- B. Draw pictures and gesture when speaking to the client.
- C. Speak very slowly when giving the client instructions.
- D. Request an interpreter from social services.
Correct Answer: D
Rationale: The nurse should request an interpreter from social services to ensure accurate communication. Using a child to interpret is inappropriate due to medical terminology and privacy concerns. Pictures, gestures, or slow speech in English are insufficient for surgical care discussions.
The nurse is caring for a 67-year-old client with postherpetic neuralgia who has a new prescription for amitriptyline. Which of the following actions would be a priority for the nurse to take?
- A. Schedule frequent rest periods for the client.
- B. Encourage the client to increase the intake of fluids.
- C. Instruct the client to stand up slowly from a sitting position.
- D. Remind the client to wear sunglasses when spending time outdoors.
Correct Answer: C
Rationale: Amitriptyline can cause orthostatic hypotension, making slow position changes a priority to prevent falls.
The nurse is caring for a client newly prescribed crutches. Which finding indicates the need for further teaching?
- A. The axillary pads are torn and show signs of wear
- B. The client has a 30-degree bend at the elbow when walking
- C. The crutches and injured foot are moved simultaneously in a 3-point gait
- D. There is a 3 finger-width space noted between the axilla and axillary pad
Correct Answer: A
Rationale: Torn axillary pads can cause discomfort and injury, indicating a need for replacement and further teaching.
An adult is admitted with Addison's disease. What type of drug does the nurse expect will be ordered for this client?
- A. Fosinopril sodium (Monopril)
- B. Fludrocortisone acetate (Florinef)
- C. Furosemide (Lasix)
- D. Fludarabine phosphate (Fludara)
Correct Answer: B
Rationale: Fludrocortisone replaces aldosterone in Addison's disease, managing sodium and fluid balance. Fosinopril, furosemide, and fludarabine do not address adrenal insufficiency.
An adult woman has been diagnosed with varicose veins. Which aspect of her history is most likely related to her diagnosis?
- A. She has had five term pregnancies.
- B. She runs several marathons a year.
- C. She is 5 feet, 6 inches tall and weighs 120 pounds.
- D. She works entering data into a computer.
Correct Answer: A
Rationale: Multiple pregnancies increase intra-abdominal pressure and venous stasis, contributing to varicose veins. Running, normal weight, and sedentary work are less directly related.