Nokea
The nurse is discharging a client who has been hospitalized for preterm labor. The client needs further instruction when the nurse is
- A. I think I have a bladder infection, I need to see my obstetrician.'
- B. If I have contractions, I should contact my health care provider.'
- C. Drinking water may help prevent early labor for me.'
- D. If I travel on long trips, I need to get out of the car every 4 hours.'
Correct Answer: A
Rationale: Suspecting a bladder infection requires immediate medical evaluation, not just a visit to the obstetrician, as infections can trigger preterm labor. The other statements reflect correct understanding of preterm labor management.
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The nurse is preparing to administer a dose of warfarin (Coumadin) to a client. The client's International Normalized Ratio (INR) is 4.0. What should the nurse do?
- A. Administer the dose as ordered.
- B. Hold the dose and notify the physician.
- C. Administer half the prescribed dose.
- D. Administer vitamin K as an antidote.
Correct Answer: B
Rationale: An INR of 4.0 is above the therapeutic range (2-3), indicating a risk of bleeding, so the nurse should hold the dose and notify the physician.
A client is hospitalized for ingesting an overdose of acetaminophen. The nurse prepares to administer which specific antidote for this medication overdose?
- A. Flumazenil
- B. Phytonadione
- C. N-acetylcysteine
- D. Naloxone hydrochloride
Correct Answer: C
Rationale: Acetylcysteine restores sulfhydryl groups that are depleted by acetaminophen metabolism. Flumazenil is the antidote for benzodiazepine reversal. Phytonadione is the antidote for warfarin sodium. Naloxone hydrochloride reverses respiratory depression caused by an opioid.
A schoolteacher asks the nurse whether all the children at school need treatment after exposure to a 7-year-old child with bacterial meningitis. The nurse responds that chemoprophylaxis should be given to:
- A. All children at the school.
- B. All household contacts and close contacts.
- C. The entire community.
- D. Household contacts only.
Correct Answer: B
Rationale: Chemoprophylaxis is recommended for household and close contacts of a child with bacterial meningitis to prevent secondary cases, not the entire school or community.
Which of the following examples should the nurse use to describe bulimia to a group of parents at a local community center?
- A. An adolescent male who uses calorie-counting to maintain his weight in the desirable range for his height.
- B. A college-age male who uses regular exercise to be able to eat and drink what he wants without gaining weight.
- C. A middle-aged female who uses diet pills occasionally to help her lose 10 lb.
- D. A college-age female who binges and then purges to prevent weight gain.
Correct Answer: D
Rationale: Bulimia is characterized by binge eating followed by purging to prevent weight gain.
A 4-year-old child is admitted with a tentative diagnosis of Kawasaki disease. Which of the following laboratory findings is most likely to be found in this child?
- A. Leukocytosis.
- B. Thrombocytopenia.
- C. Decreased sedimentation rate.
- D. Hypoalbuminemia.
Correct Answer: A
Rationale: Kawasaki disease is commonly associated with leukocytosis, reflecting the inflammatory process characteristic of the condition.