Nokea
The nurse is collecting data from a client at 15 weeks gestation who has hyperemesis gravidarum. Which of the following findings would be consistent with the condition?
- A. decreased urine specific gravity
- B. blood pressure >=140/90 mm Hg
- C. urinalysis positive for ketones
- D. bradycardia
Correct Answer: C
Rationale: Hyperemesis gravidarum causes severe vomiting, leading to dehydration and starvation, resulting in ketosis. Positive ketones in urinalysis confirm this metabolic state.
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Health care provider prescription
Guaifenesin 600 mg/dextromethorphan hydrobromide 30 mg ER one tablet PO q12h PRN for thick secretions
The nurse prepares to administer an oral expectorant to a client with pneumonia. The client tells the nurse, 'That pill is too big. I won't be able to swallow it.' What is the best action by the nurse?
- A. Contact the pharmacy and request the liquid form of the medication.
- B. Crush the medication and place it in a small amount of applesauce.
- C. Instruct the client to tuck chin to chest while swallowing the tablet.
- D. Obtain a new prescription for the liquid form of the medication.
Correct Answer: A
Rationale: Contacting the pharmacy for a liquid form addresses the client's difficulty swallowing the pill, ensuring medication adherence without altering the drug inappropriately.
The nurse is collecting data from a client with heart failure. The nurse notes that the client is agitated, has crackles bilaterally, and is reporting dyspnea and anxiety. The nurse should place the client in
- A. modified Trendelenburg position
- B. high Fowler position
- C. left Sims position
- D. supine position
Correct Answer: B
Rationale: High Fowler position optimizes lung expansion and reduces preload, alleviating dyspnea and crackles in acute heart failure exacerbation.
The nurse assesses a child with intussusception. Which assessment findings require priority intervention?
- A. Abdominal rigidity with guarding
- B. Absence of tears in crying child with IV start
- C. Blood-streaked mucous stool in diaper
- D. Sausage-shaped right-sided mass on palpation
Correct Answer: A
Rationale: Abdominal rigidity with guarding suggests peritonitis or perforation, critical complications of intussusception requiring immediate surgical intervention.
The mother of 6-month-old twins is in the doctor's office because one of the infants has an ear infection. The mother says to the nurse, 'I just don't know if I can handle another problem. It is all so overwhelming.' How should the nurse respond initially?
- A. You're their mother. I'm sure you know what's best for them.'
- B. Have you called social services to see if you qualify for assistance?'
- C. My sister had twins and she survived. You will too.'
- D. It must be tough to have two little ones. What seems to be the biggest problem?'
Correct Answer: D
Rationale: Acknowledging the mother's stress and exploring her challenges builds rapport and identifies support needs. Other responses dismiss or redirect her concerns.
A 35 year-old client with sickle cell crisis is talking on the telephone but stops as the nurse enters the room to request something for pain. The nurse should
- A. Administer a placebo
- B. Encourage increased fluid intake
- C. Administer the prescribed analgesia
- D. Recommend relaxation exercises for pain control
Correct Answer: C
Rationale: Administer the prescribed analgesia. Pain relief is a priority in sickle cell crisis, and prescribed analgesics are appropriate.