Nokea
The nurse is caring for a client with a diagnosis of chorioamnionitis. Which intervention is most appropriate?
- A. Administer antibiotics
- B. Monitor fetal heart tones
- C. Prepare for delivery
- D. All of the above
Correct Answer: D
Rationale: Chorioamnionitis requires antibiotics for infection fetal heart tone monitoring for distress and preparation for delivery (vaginal or cesarean) if maternal or fetal condition worsens. All interventions are appropriate.
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Due to his prolonged history of alcohol abuse, an alcoholic client will most likely have deficiencies of which of the following nutrients?
- A. Vitamin C and zinc
- B. Folic acid and niacin
- C. Vitamin A and biotin
- D. Thiamine and pyroxidine
Correct Answer: D
Rationale: Chronic alcoholism can lead to deficiencies of B complex vitamins including thiamine and pyroxidine.
The nurse is preparing to administer a dose of enoxaparin (Lovenox) to a client. Which injection site is most appropriate?
- A. Deltoid muscle
- B. Ventrogluteal muscle
- C. Anterolateral thigh
- D. Abdomen, 2 inches from the umbilicus
Correct Answer: D
Rationale: Enoxaparin, a low-molecular-weight heparin, is administered subcutaneously in the abdomen, 2 inches from the umbilicus, to ensure consistent absorption and minimize bruising. Muscle injections are inappropriate.
A client with gallstones and obstructive jaundice is experiencing severe itching. The physician has prescribed cholestyramine (Questran). The client asks, “How does this drug work?” What is the nurse’s best response?
- A. “It blocks histamine, reducing the allergic response.”
- B. “It inhibits the enzyme responsible for bile excretion.”
- C. “It decreases the amount of bile in the gallbladder.”
- D. “It binds with bile acids and is excreted in bowel movements with stool.”
Correct Answer: D
Rationale: Cholestyramine binds bile acids in the intestine, forming complexes excreted in stool, reducing circulating bile acids that cause itching. It doesn’t block histamine (A), inhibit enzymes (B), or reduce gallbladder bile (C).
A 40-year-old client is admitted to the hospital for tests to diagnose cancer. Since his admission, he has become dependent and demanding to the nursing staff. The nurse identifies this behavior as which defense mechanism?
- A. Denial
- B. Displacement
- C. Regression
- D. Projection
Correct Answer: C
Rationale: Regression involves reverting to an earlier developmental stage, such as dependency, in response to stress like a cancer diagnosis.
Which of the following is an adverse effect associated with the use of Adriamycin (doxorubicin)?
- A. Ventricular arrhythmias
- B. Alopecia
- C. Leukopenia
- D. Stomatitis
Correct Answer: B
Rationale: Alopecia (hair loss) is a common adverse effect of doxorubicin, a chemotherapeutic agent, due to its impact on rapidly dividing cells, including hair follicles.