Nokea
The nurse is making room assignments for four obstetrical clients. If only one private room is available, it should be assigned to:
- A. A multigravida with diabetes mellitus
- B. A primigravida with preeclampsia
- C. A multigravida with preterm labor
- D. A primigravida with hyperemesis gravidarum
Correct Answer: B
Rationale: Preeclampsia requires close monitoring due to risks like seizures or stroke, making a private room essential for a primigravida with this condition.
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The nurse is caring for a client with a history of a retinal detachment who is scheduled for a scleral buckling procedure. The nurse should:
- A. Position the client flat in bed
- B. Administer eye drops as ordered
- C. Restrict fluids before surgery
- D. Encourage deep breathing exercises
Correct Answer: B
Rationale: Eye drops (e.g., mydriatics) are often ordered pre-scleral buckling to dilate the pupil or reduce pressure. Flat positioning, fluid restriction, and breathing exercises are not standard.
A home health nurse has several elderly clients in her case load. Which of the following clients ~(is most likely to be a victim of elder abuse?
- A. A 76-year-old female with Alzheimer's dementia
- B. A 70-year-old male with diabetes mellitus
- C. A 64-year-old female with a hip replacement
- D. A 72-year-old male with Parkinson's disease
Correct Answer: A
Rationale: Elderly clients with Alzheimer's dementia are at highest risk for abuse due to cognitive impairment, dependency, and potential caregiver stress. The other conditions pose less risk.
A client with a history of atrial flutter is admitted with complaints of dizziness. The nurse should give priority to:
- A. Monitoring heart rate
- B. Administering pain medication
- C. Monitoring respiratory rate
- D. Administering diuretics
Correct Answer: A
Rationale: Atrial flutter causes rapid heart rates, which can lead to dizziness due to reduced cardiac output, so monitoring heart rate is the priority.
Which nursing implication is appropriate for a client undergoing a paracentesis?
- A. Have the client void before the procedure.
- B. Keep the client NPO.
- C. Observe the client for hypertension following the procedure.
- D. Place the client on the right side following the procedure.
Correct Answer: A
Rationale: A full bladder impedes ascitic fluid withdrawal during paracentesis, so the client should void beforehand.
A client with multiple sclerosis has an order to receive Solu Medrol 200mg IV push. The available dose is Solu Medrol 250 mg per mL. How many mL should the nurse administer?
Correct Answer: 0.8
Rationale: Dose: 200 mg ÷ 250 mg/mL = 0.8 mL. The nurse should administer 0.8 mL.