Nokea
The nurse is reinforcing teaching to a client, gravida 1 para 0, at 8 weeks gestation about expected weight gain during pregnancy. The client's prepregnancy BMI is 21 kg/m?. Which statement made by the client indicates an appropriate understanding about weight gain?
- A. I should gain 10-15 pounds during the first trimester.
- B. I should gain about 30 pounds during the entire pregnancy!
- C. I should gain no more than half a pound per week during the third trimester
- D. If I gain less than 20 pounds during pregnancy, it will be easier to lose weight postpartum
Correct Answer: B
Rationale: Appropriate weight gain during pregnancy decreases risks to the client and fetus. Optimal weight gain is determined by prepregnancy BMI. Underweight clients need to gain more weight (~1 lb [0.5 kg] per week) during the second and third trimesters of pregnancy than obese clients (~0.5 lb [0.2 kg] per week). However, weight gain in the first trimester should be 1.1-4.4 lb (0.5-2.0 kg), regardless of BMI.
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Which discharge teaching instructions should the nurse reinforce to the parents of a 2-year-old with group A streptococcal pharyngitis? Select all that apply.
- A. Complete all the antibiotics even if your child is feeling better
- B. Cool liquids and soft diet are recommended
- C. Keep your child home from daycare for at least a week
- D. Replace your child’s toothbrush 24 hours after starting antibiotics
- E. Throat lozenges may soothe your child’s sore throat
Correct Answer: A,B,D
Rationale: Completing antibiotics prevents resistance, cool liquids/soft foods ease swallowing, and replacing the toothbrush prevents reinfection. A week-long daycare exclusion is excessive (24-48 hours post-antibiotics is sufficient), and lozenges are unsafe for a 2-year-old due to choking risk.
The nurse is working with unlicensed assistive personnel (UAP). Which task can the nurse safely assign to UAP?
- A. Assisting a 2-day postoperative hip arthroplasty client with morning care
- B. Collecting a urine specimen for culture and sensitivity from a client with a Foley catheter
- C. Irrigating colostomy of a 2-day postoperative colostomy client who is stable
- D. Refilling the empty enteral feeding container with tube feeding
Correct Answer: B
Rationale: Collecting a urine specimen from a Foley catheter is within the UAP's scope, as it involves a straightforward procedure with proper training. Colostomy irrigation and refilling enteral feeding containers require nursing judgment and are not safe for UAP to perform.
A health care provider is screaming at the nurse in the hallway. 'Why didn't you get that surgery scheduled sooner?' What is the best response by the nurse?
- A. I am so sorry; I will get this fixed and schedule the surgery immediately
- B. I am uncomfortable with your tone, please excuse me while I locate my supervisor
- C. I delegated this task to the unlicensed assistive personnel: please follow up with them.
- D. I think you are overreacting, you should have specified the day and time
Correct Answer: B
Rationale: Responding calmly and redirecting to a supervisor de-escalates the situation professionally while addressing the inappropriate tone. Accusing the provider of overreacting is confrontational and unprofessional.
A client is given an opiate drug for pain relief following general anesthesia. The client becomes extremely somnolent with respiratory depression. The physician is likely to order the administration of:
- A. naloxone (Narcan).
- B. labetalol (Normodyne).
- C. neostigmine (Prostigmin).
- D. thiothixene (Navane).
Correct Answer: A
Rationale: Naloxone reverses opioid-induced respiratory depression and somnolence by antagonizing opioid receptors. The other medications have different indications and do not address opioid overdose. Pharmacological Therapies
A client comes to the emergency department reporting alkaline drain cleaner splashed into the eye. The conjunctiva of the affected eye is erythematous, and the client reports a burning sensation. What action is appropriate at this time?
- A. Administer PO analgesic medication
- B. Cover the affected eye with an eye patch
- C. Initiate continuous eye irrigation
- D. Perform a Snellen vision test
Correct Answer: C
Rationale: Ocular chemical burns require emergency care to prevent permanent vision loss. Alkali burns (eg, ammonia, cement, lye- containing drain cleanser) are particularly dangerous as they will quickly penetrate deep into the eye, causing severe, irreversible damage. For all types of ocular chemical burns, copious eye irrigation with sterile saline or water should begin immediately to flush the chemical irritant out of the eye