Nokea
The nurse is caring for a pregnant client at 24 weeks. The client voids before the nurse measures the fundal height. Which finding by the nurse would be expected in assessment of this client?
- A. a fundal height of 22 to 26 cm
- B. a fundal height of 27 to 30 cm
- C. a fundal height of 29 to 33 cm
- D. a fundal height of 31 to 34 cm
Correct Answer: A
Rationale: At 24 weeks, fundal height typically measures 22-26 cm, corresponding to gestational age in centimeters.
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Dipyridamole has been prescribed for the client who underwent a valve replacement, and the nurse has provided teaching to the client about the medication. Which statement indicates that the client understands the medication instructions?
- A. This medication will prevent a stroke.
- B. This medication will prevent a heart attack.
- C. This medicine will protect my artificial heart valve.
- D. This medication will help me keep my blood pressure down.
Correct Answer: C
Rationale: Dipyridamole is an antiplatelet medication. It may be administered in combination with warfarin sodium to protect the client's artificial heart valves. Dipyridamole does not prevent stroke or heart attacks. It is an antiplatelet medication rather than an antihypertensive.
The nurse has completed discharge teaching with the parents of a child diagnosed with glomerulonephritis. Which statement by the parents indicates that further teaching is necessary?
- A. We'll check our child's blood pressure every day.
- B. We'll test our child's urine for albumin every week.
- C. It'll be so good to have our child back in tap-dancing classes next week.
- D. We'll be sure that our child eats a lot of vegetables and does not add extra salt to food.
Correct Answer: C
Rationale: Tap dancing classes 1 week after discharge would be unrealistic and involve a too rapid increase in activity. Glomerulonephritis results in destruction, inflammation, and sclerosis of the glomeruli of the kidneys. After discharge, parents should allow the child to return to his or her normal routine and activities, with adequate periods allowed for rest. Taking daily blood pressure, testing urine weekly for albumin, and restricting extra sodium are appropriate home care measures.
A nurse is caring for a client with dumping syndrome. Which statement by the client indicates a need for further teaching?
- A. I should lie down after I eat my meals.
- B. I may experience weakness and dizziness.
- C. I should eat a low-fat, high-protein, low-carbohydrate diet.
- D. I should eat small meals and avoid drinking fluids with my meals.
Correct Answer: C
Rationale: Dumping syndrome requires a high-fat, low-carbohydrate diet to slow gastric emptying. Other statements are correct.
The nurse is teaching a client with a right-leg fracture who has a prescription for partial weight-bearing status how to ambulate with crutches. The nurse determines that the client demonstrates compliance with this restriction to prevent complications of the fracture if the client follows which direction?
- A. Allows the right foot to only touch the floor
- B. Does not bear any weight on the right leg/foot
- C. Puts 30 \% to 50 \% of the weight on the right leg/foot
- D. Puts 60 \% to 80 \% of the weight on the right leg/foot
Correct Answer: C
Rationale: The client who has partial weight-bearing status is allowed to place 30 \% to 50 \% of the body weight on the affected limb. Touchdown weight-bearing allows the client to let the limb touch the floor but not to bear weight. Nonweight-bearing status does not allow the client to let the limb touch the floor. There is no classification for 60 \% to 80 \% weight-bearing status. Full weightbearing status involves placing full weight on the limb.
The nurse is giving a client with chronic obstructive pulmonary disease (COPD) information related to the positions used to breathe more easily. The nurse teaches the client to assume which position?
- A. Sit bolt upright in bed with the arms crossed over the chest.
- B. Lie on the side with the head of the bed at a 45-degree angle.
- C. Sit in a reclining chair tilted slightly back with the feet elevated.
- D. Sit on the edge of the bed with the arms leaning on an overbed table.
Correct Answer: D
Rationale: Proper positioning can decrease episodes of dyspnea in a client with COPD. Appropriate positions include sitting upright while leaning on an overbed table, sitting upright in a chair with the arms resting on the knees, and leaning against a wall while standing. Sitting bolt upright with arms folded across the chest restricts the movement of the anterior and posterior walls of the lung, and side-lying with the head of bed raised to a 45-degree position restricts the expansion of the lateral wall of the lung. Option 3 restricts posterior lung expansion.