Nokea
The nurse is caring for a client with a diagnosis of gestational hypertension. Which intervention is most appropriate?
- A. Monitor blood pressure
- B. Administer antihypertensives
- C. Monitor fetal heart tones
- D. All of the above
Correct Answer: D
Rationale: Gestational hypertension requires blood pressure monitoring to assess severity antihypertensives for severe hypertension and fetal heart tone monitoring to ensure fetal well-being. All interventions are appropriate.
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A client with a history of hypertension is receiving Aldactone (spironolactone). The nurse should teach the client to avoid:
- A. Potassium-rich foods
- B. Calcium supplements
- C. High-fiber foods
- D. Iron supplements
Correct Answer: A
Rationale: Spironolactone is a potassium-sparing diuretic, and consuming potassium-rich foods can lead to hyperkalemia. Calcium, fiber, and iron supplements are not contraindicated.
A client is in early labor. Her fetus is in a left occipitoanterior (LOA) position; fetal heart sounds are best auscultated just:
- A. Below the umbilicus toward left side of mother's abdomen
- B. Below the umbilicus toward right side of mother's abdomen
- C. At the umbilicus
- D. Above the umbilicus to the left side of mother's abdomen
Correct Answer: A
Rationale: In LOA, the fetus's back is on the mother's left anterior side, so fetal heart sounds are best heard below the umbilicus on the left.
Prior to administering digoxin to a client with congestive heart failure, the nurse needs to assess:
- A. Respiratory rate for 1 minute
- B. Radial pulse for 1 minute
- C. Radial pulse for 2 minutes
- D. Apical pulse for 1 minute
Correct Answer: D
Rationale: Apical pulse should be measured for 1-minute prior to digoxin administration. Digoxin decreases the heart rate. Digoxin should be withheld if apical rates are <60 bpm or >120 bpm.
A client with a history of hypothyroidism is admitted with complaints of fatigue. The nurse should expect the client to have:
- A. Weight gain
- B. Weight loss
- C. Tachycardia
- D. Diarrhea
Correct Answer: A
Rationale: Hypothyroidism slows metabolism, leading to weight gain, fatigue, and other symptoms like cold intolerance and constipation.
The nurse is making room assignments for four obstetrical clients. If only one private room is available, it should be assigned to:
- A. A multigravida with diabetes mellitus
- B. A primigravida with preeclampsia
- C. A multigravida with preterm labor
- D. A primigravida with hyperemesis gravidarum
Correct Answer: B
Rationale: Preeclampsia requires close monitoring due to risks like seizures or stroke, making a private room essential for a primigravida with this condition.