Nokea
The nurse is caring for a client with a diagnosis of gestational diabetes. Which laboratory test is most appropriate to monitor?
- A. Hemoglobin A1c
- B. Fasting blood glucose
- C. Both A and B
- D. Neither A nor B
Correct Answer: C
Rationale: Hemoglobin A1c reflects long-term glucose control and fasting blood glucose monitors daily management in gestational diabetes. Both tests are appropriate to ensure optimal maternal and fetal outcomes.
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Diphenoxylate hydrochloride and atropine sulfate (Lomotil) is prescribed for the client with ulcerative colitis. Which of the following nursing observations indicates that the drug is having a therapeutic effect?
- A. There is an absence of peristalsis.
- B. The number of diarrhea stools decreases.
- C. Cramping in the abdomen has increased.
- D. Abdominal girth size increases.
Correct Answer: B
Rationale: Lomotil, an antidiarrheal, slows intestinal motility, reducing diarrhea frequency in ulcerative colitis. Decreased diarrhea stools (B) indicates therapeutic effect. Absent peristalsis (A), increased cramping (C), or girth (D) suggest complications or ineffectiveness.
A 17-year-old client has a T-4 spinal cord injury. At present, he is learning to catheterize himself. When he says, 'This is too much trouble. I would rather just have a Foley.' An appropriate response for the RN teaching him would be:
- A. I know. It is a lot to learn. In the long run, though, you will be able to reduce infections if you do an intermittent catheterization program.
- B. It is not too much trouble. This is the best way to manage urination.
- C. OK. I'll ask your physician if we can replace the Foley.
- D. You need to learn this because your doctor ordered it.
Correct Answer: A
Rationale: This response validates the client's feelings, provides education on reduced infection risk with intermittent catheterization, and encourages autonomy.
A client with a history of a gastrectomy is being taught about dietary management. The nurse should encourage the client to:
- A. Eat six small meals a day
- B. Avoid fluids with meals
- C. Eat high-fiber foods
- D. Take a multivitamin daily
Correct Answer: A
Rationale: After a gastrectomy, eating six small meals a day prevents dumping syndrome by reducing gastric overload. Avoiding fluids with meals and taking vitamins are helpful, but small meals are primary.
A client delivered a term infant 1 hour ago. Her uterus on assessment is boggy and is U+1 in contrast to the previous assessment of U-2. The immediate nursing response is to:
- A. Administer methergine IM
- B. Remove the retained placental fragments
- C. Assist the client to the bathroom and provide cues to stimulate urination
- D. Massage the fundus until firm
Correct Answer: D
Rationale: Methergine is given following placental delivery to promote uterine contractions and prevent hemorrhage. Methergine may be administered in this clinical situation, but fundal massage would be the first response. Removal of retained placental fragments is done by the physician and is not the first response. If the fundus rises and is deviated, particularly to the right, the nurse should suspect bladder distention secondary to bladder and urethral trauma associated with birth and decreased bladder tone following delivery. Therefore, women have a diminished sensation to void. A boggy fundus rises and is indicative of blood pooling, predisposing the woman to clot formation. Massage the uterus until firm. Too vigorous massage will result in atonia. Clots may be expelled by a kneading motion of the uterus by the nurse.
The client is admitted with a diagnosis of molar pregnancy. Which symptom is most likely to be present?
- A. Severe nausea and vomiting
- B. Uterine size smaller than expected
- C. Fetal heart tones at 12 weeks
- D. All of the above
Correct Answer: A
Rationale: Molar pregnancy (hydatidiform mole) often causes severe nausea and vomiting due to high levels of human chorionic gonadotropin (hCG). The uterus is typically larger than expected and fetal heart tones are absent as there is no viable fetus.