Nokea
The nurse is caring for a client with a suspected stroke. Which of the following actions should the nurse perform FIRST?
- A. Administer aspirin 325 mg PO.
- B. Obtain a CT scan of the head.
- C. Check the client’s blood glucose level.
- D. Start an IV line.
Correct Answer: C
Rationale: Hypoglycemia can mimic stroke symptoms; checking blood glucose is the first step to rule out treatable causes. Options A, B, and D are secondary.
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The physician has prescribed hydralazine (Apresoline) for a client with acute glomerulonephritis. Which finding indicates that the drug is having the desired effect?
- A. The client's appetite has improved.
- B. Creatinine levels have returned to normal.
- C. The client's blood pressure has decreased.
- D. Urinary output is amber in color.
Correct Answer: C
Rationale: Apresoline (hydralazine) is an antihypertensive; therefore, a decrease in blood pressure indicates the medication is working. Answers A, B, and D indicate that the overall condition of the client is improving, but they are not the result of the medication.
The nurse is assessing a pregnant client in her third trimester. The parents are informed that the ultrasound suggests that the baby is small for gestational age (SGA). An earlier ultrasound indicated normal growth. The nurse understands that this change is most likely due to what factor?
- A. Sexually transmitted infection
- B. Exposure to teratogens
- C. Maternal hypertension
- D. Chromosomal abnormalities
Correct Answer: C
Rationale: Maternal hypertension. Pregnancy induced hypertension is a common cause of late pregnancy fetal growth retardation. Vasoconstriction reduces placental exchange of oxygen and nutrients.
A 25-year-old primigravida with type I diabetes mellitus.
The nurse explains to the client that her insulin needs will
- A. increase during pregnancy and decrease after delivery.
- B. decrease during pregnancy and increase after delivery.
- C. increase during pregnancy and remain increased after delivery.
- D. decrease during pregnancy and fluctuate after delivery.
Correct Answer: A
Rationale: Strategy: Think about each answer choice. (1) correct-needs increase during pregnancy due to hormonal interference in glucose metabolism (2) needs increase during pregnancy due to hormonal interference in glucose metabolism (3) insulin needs will decrease after delivery (4) needs increase during pregnancy
A 30-year-old woman is admitted to the hospital with dry mucous membranes and decreased skin turgor. The woman's vital signs are BP 120/70, temperature 101°F (38.3°C), pulse 88, respirations 14. Laboratory Test s indicate the serum sodium is 150 mEq/L and the Hct is 48%.
The nurse would expect the physician to order which of the following IV fluids?
- A. D5 NS.
- B. 0.45% NaCl.
- C. 0.9% NaCl.
- D. Lactated Ringer's.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) hypertonic solutions contraindicated in dehydration (2) correct-hypotonic solution, shifts fluid into intracellular space to correct dehydration (3) isotonic solution, not best with dehydration (4) isotonic solution used to replace electrolytes
The client with cancer has an order for Adriamycin. Which of the following untoward effects is of particular concern to the nurse?
- A. Alopecia
- B. Fatigue
- C. Dysrhythmias
- D. Nausea
Correct Answer: C
Rationale: Adriamycin (doxorubicin) is cardiotoxic, and dysrhythmias are a serious concern. Alopecia, fatigue, and nausea are common but less life-threatening.