Nokea
The nurse is monitoring a client with severe preeclampsia. What assessment finding requires immediate intervention?
- A. Blood pressure of 150/90 mmHg.
- B. Urine output of 25 mL/hr.
- C. Headache relieved by acetaminophen.
- D. Deep tendon reflexes +2.
Correct Answer: B
Rationale: Oliguria (urine output <30 mL/hr) may indicate worsening renal function or severe complications in preeclampsia.
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The nurse is assessing a client with hyperemesis gravidarum. What finding requires immediate intervention?
- A. Urine output of 50 mL/hr.
- B. Weight loss of 5 pounds in 2 weeks.
- C. Dry mucous membranes and poor skin turgor.
- D. Nausea relieved by eating crackers.
Correct Answer: C
Rationale: Dehydration, indicated by dry mucous membranes and poor skin turgor, requires immediate intervention in hyperemesis gravidarum.
What nursing intervention is appropriate for a woman diagnosed with syphilis?
- A. Council the woman about how to live with a chronic infection.
- B. Question the woman regarding symptoms of other sexually transmitted infections.
- C. Assist the primary health care practitioner with cryotherapy procedures.
- D. Educate the woman regarding the safe disposal of menstrual pads.
Correct Answer: B
Rationale: Syphilis often coexists with other STIs, so questioning is important.
What should be included in teaching a young woman how to use the female condom?
- A. Reuse female condoms no more than five times.
- B. Refrain from using lubricant because the condom may slip out of the vagina.
- C. Wear both female and male condoms together to maximize effectiveness.
- D. Remove the condom by twisting the outer ring and pulling gently.
Correct Answer: D
Rationale: Twisting the outer ring prevents spillage of semen.
A nurse is providing discharge teaching to a client who is 3 days postoperative following a cesarean birth. Which of the following client statements should indicate to the nurse the
- A. "I am likely to have a fever during the first week I am home."
- B. "I will resume taking my prenatal vitamins."
- C. "I will call my provider if I have discharge from my incision."
- D. "I should not have unrelieved pain in my abdomen."
Correct Answer: C
Rationale: The correct statement that should indicate to the nurse that the client understands the discharge teaching is "I will call my provider if I have discharge from my incision." This response demonstrates the client's understanding of the importance of monitoring the incision site for signs of infection or complications. It shows that the client is aware of the potential risks postoperatively and is prepared to take necessary action by notifying the healthcare provider if any issues arise. Monitoring incision discharge is essential to prevent infection and ensure proper healing after a cesarean birth.
A pregnant client is diagnosed with anemia. What dietary recommendation should the nurse provide?
- A. Increase intake of dairy products.
- B. Consume more lean red meat.
- C. Drink tea with meals.
- D. Avoid citrus fruits.
Correct Answer: B
Rationale: Lean red meat is rich in iron, which is essential for managing anemia during pregnancy.