Nokea
The nurse is caring for a client with a diagnosis of placenta accreta. Which intervention is most appropriate?
- A. Prepare for possible hysterectomy
- B. Administer tocolytics
- C. Monitor fetal heart tones
- D. Administer antibiotics
Correct Answer: A
Rationale: Placenta accreta often prevents placental separation leading to severe hemorrhage during delivery which may necessitate hysterectomy. Tocolytics fetal monitoring and antibiotics are not primary interventions for this condition.
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A client had abdominal surgery this morning. The nurse notices that there is a small amount of bloody drainage on his surgical dressing. The nurse would document this as what type of drainage?
- A. Serosanguinous
- B. Purulent
- C. Sanguinous
- D. Catarrhal
Correct Answer: C
Rationale: Drainage from a surgical incision is initially sanguinous, proceeding to serosanguinous, and then to serous.
A client with a history of a brain tumor is receiving Decadron (dexamethasone). The nurse should monitor the client for:
- A. Weight gain
- B. Hypotension
- C. Hypoglycemia
- D. Hair loss
Correct Answer: A
Rationale: Dexamethasone, a corticosteroid, causes weight gain due to fluid retention and increased appetite. Hypotension, hypoglycemia, and hair loss are not typical side effects.
Which of the following menu choices would indicate that a client with pressure ulcers understands the role diet plays in restoring her albumin levels?
- A. Broiled fish with rice
- B. Bran flakes with fresh peaches
- C. Lasagna with garlic bread
- D. Cauliflower and lettuce salad
Correct Answer: A
Rationale: Broiled fish and rice are excellent protein sources, aiding in restoring albumin levels for tissue repair. The other options are lower in protein.
The nurse is caring for a client with a history of a pulmonary embolism who is receiving Warfarin (Coumadin). The nurse should monitor the client for:
- A. Bleeding
- B. Hypertension
- C. Tachypnea
- D. Fever
Correct Answer: A
Rationale: Warfarin, an anticoagulant, increases bleeding risk, requiring monitoring for signs like epistaxis or hematuria. Hypertension, tachypnea, and fever are not primary concerns.
The nurse is caring for a client with a history of a retinal detachment who is scheduled for a scleral buckling procedure. The nurse should:
- A. Position the client flat in bed
- B. Administer eye drops as ordered
- C. Restrict fluids before surgery
- D. Encourage deep breathing exercises
Correct Answer: B
Rationale: Eye drops (e.g., mydriatics) are often ordered pre-scleral buckling to dilate the pupil or reduce pressure. Flat positioning, fluid restriction, and breathing exercises are not standard.