Nokea
The nurse is caring for a client with a diagnosis of postpartum depression. Which intervention is most appropriate?
- A. Refer to a psychiatrist
- B. Administer antibiotics
- C. Monitor fetal heart tones
- D. Administer tocolytics
Correct Answer: A
Rationale: Postpartum depression requires mental health intervention such as referral to a psychiatrist for therapy or medication. Antibiotics fetal monitoring and tocolytics are irrelevant to this condition.
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The client is admitted with a diagnosis of postpartum depression. Which medication is most likely to be ordered?
- A. Antibiotics
- B. Antidepressants
- C. Magnesium sulfate
- D. Tocolytics
Correct Answer: B
Rationale: Postpartum depression is treated with antidepressants (e.g. SSRIs) to address mood symptoms. Antibiotics magnesium sulfate and tocolytics are used for other conditions not depression.
Which finding in the patient's history contraindicates the use of Imitrex (sumatriptan) for the prevention of migraine headaches?
- A. Diabetes
- B. Angina
- C. Renal calculi
- D. Peptic ulcer disease
Correct Answer: B
Rationale: Sumatriptan (Imitrex) is a vasoconstrictor contraindicated in patients with angina due to the risk of coronary artery vasoconstriction and ischemia. Diabetes renal calculi and peptic ulcer disease are not contraindications for sumatriptan.
The school nurse is assessing an elementary student with hemophilia who fell during recess. Which symptoms indicate hemarthrosis?
- A. Pain, coolness, and blue discoloration in the affected joint
- B. Tingling and pain without loss of movement in the affected joint
- C. Warmth, redness, and decreased movement in the affected joint
- D. Stiffness, aching, and decreased movement in the affected joint
Correct Answer: D
Rationale: Hemarthrosis in hemophilia involves bleeding into joints, causing stiffness, aching, and decreased movement due to joint swelling and pain.
A client is diagnosed with diabetic ketoacidosis. The nurse should be prepared to administer which of the following IV solutions?
- A. D5 in normal saline
- B. D5W
- C. 0.9 normal saline
- D. D5 in lactated Ringer's
Correct Answer: C
Rationale: A concentration of 0.9 NS is used to correct extracellular fluid depletion.
While changing the dressing on a client's central line, the nurse notices redness and warmth at the needle insertion site. Which of the following actions would be appropriate to implement based on this finding?
- A. Discontinue the central line.
- B. Begin a peripheral IV.
- C. Document in the nurse's notes and notify the physician after redressing the site.
- D. Clean the site well and redress.
Correct Answer: C
Rationale: The nurse should always document findings and alert the physician to the findings as well. The physician may then initiate a new central line and order the current central line to be discontinued.