Nokea
The nurse is reviewing laboratory results in the adolescent's medical
record.
Exhibit 1
Vital Signs
1300:
Blood pressure 118/72 mm Hg
Heart rate 100/min
Respiratory rate 20/min
Temperature 38.3° C (101° F)
The nurse is reviewing the adolescent's medical record. Which of the following conditions is the client most likely developing? Complete the following sentence by using the list of options. The adolescent is most likely developing -------------------------- evidenced by --------------------------
- A. Pelvic inflammatory disease
- B. Ectopic pregnancy
- C. C-reactive protein
- D. Beta hCG level
- E. Urinalysis
Correct Answer:
Rationale: Correct Answer: A: Pelvic inflammatory disease
Rationale: Pelvic inflammatory disease (PID) is a common condition in adolescents due to sexually transmitted infections. The nurse reviewing the medical record indicates a focus on the reproductive system. Ectopic pregnancy and Beta hCG levels are related but not the most likely in this case. C-reactive protein and urinalysis are general tests not specific to PID.
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A nurse is caring for a client following an amniocentesis at 18 weeks of gestation. Which of the following findings should the nurse report to the provider as a potential complication?
- A. Increased fetal movement.
- B. Leakage of fluid from the vagina.
- C. Upper abdominal discomfort.
- D. Urinary frequency.
Correct Answer: B
Rationale: The correct answer is B: Leakage of fluid from the vagina. Following an amniocentesis, leakage of fluid from the vagina can indicate a potential complication such as amniotic fluid leakage, which can lead to preterm labor or infection. This finding should be reported to the provider promptly for further evaluation and management. Increased fetal movement (choice A) is a normal occurrence and not typically indicative of a complication. Upper abdominal discomfort (choice C) and urinary frequency (choice D) are common side effects post-amniocentesis and usually resolve without intervention.
A nurse is planning care for a client who is in labor and is to have an amniotomy. Which of the following assessments should the nurse identify as the priority?
- A. O2 saturation.
- B. Temperature.
- C. Blood pressure.
- D. Urinary output.
Correct Answer: B
Rationale: The correct answer is B: Temperature. During an amniotomy, there is a risk of infection due to the introduction of bacteria into the amniotic sac. Monitoring the client's temperature is crucial as fever can indicate infection, which can be life-threatening for both the client and the fetus. It is essential to detect early signs of infection to initiate prompt treatment. Assessing O2 saturation, blood pressure, and urinary output are important but not the priority in this situation. O2 saturation may be monitored if there are concerns about fetal distress, blood pressure for signs of preeclampsia, and urinary output for kidney function, but these are not immediate concerns post-amniotomy.
A nurse is caring for a postpartum client who is receiving heparin via a continuous IV infusion for thrombophlebitis in their left calf. Which of the following actions should the nurse take?
- A. Administer aspirin for pain.
- B. Maintain the client on bed rest.
- C. Massage the affected leg every 12 hr.
- D. Apply cold compresses to the affected calf.
Correct Answer: B
Rationale: The correct answer is B: Maintain the client on bed rest. In a client receiving heparin for thrombophlebitis, bed rest is essential to prevent dislodgment of the clot and avoid further complications. Moving around can increase the risk of embolism. Administering aspirin (choice A) is not recommended as it can increase the risk of bleeding with heparin. Massaging the affected leg (choice C) can dislodge the clot leading to embolism. Applying cold compresses (choice D) can also increase the risk of dislodging the clot. The key is to promote circulation without dislodging the clot, which is achieved by keeping the client on bed rest.
A nurse is reviewing the provider's prescription in the adolescent's medical chart
Exhibit 1
History and Physical, Adolescent is sexually active with two current partners.
IUD in place, Reports not using condoms during sexual activity.
History of type 1 diabetes mellitus
Which of the following indicates whether the adolescent understands the teaching on requires further education?
- A. I should continue taking all my medications even if I don't show any symptoms.
- B. If I continue to get this type of infection, it can affect my ability to have kids in the future.
- C. I should go to the emergency department if my urine turns dark.
- D. As long as I keep my IUD, I don't need to use condoms.
- E. I'm more likely to get a sunburn while taking these medications.
Correct Answer: D
Rationale: Step-by-step rationale for why answer D is correct:
1. Choice D states, "As long as I keep my IUD, I don't need to use condoms." This statement indicates a misunderstanding as IUDs do not protect against sexually transmitted infections .
2. This statement shows a lack of understanding regarding the importance of using condoms to prevent STIs.
3. Therefore, selecting Choice D indicates that further education is required to clarify the misconception about the role of IUDs in STI prevention.
Summary:
- Choice A is correct as it indicates a misunderstanding about the necessity of taking medications regardless of symptoms.
- Choice B is correct as it states a potential consequence of untreated infections, showing understanding.
- Choice C is correct as it highlights a symptom that warrants immediate medical attention.
- Choice E is incorrect as it does not pertain to the understanding of contraception and STI prevention.
- Choices F and G are not applicable and can be disregarded.
A nurse is preparing to administer azithromycin to a client who is at 16 weeks of gestation and has a positive chlamydia culture. The prescription states "Administer azithromycin 1 g orally now." Available are 250 mg tablets. How many tablets should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
- A. 8 tablets
- B. 6 tablets
- C. 4 tablets
- D. 2 tablets
Correct Answer: C
Rationale: The correct answer is C: 4 tablets. Azithromycin 1g is equivalent to 1000mg. Since each tablet is 250mg, the nurse should administer 1000mg/250mg = 4 tablets. This dosage is appropriate for treating chlamydia infection. Choice A is incorrect because 8 tablets would be equivalent to 2000mg, which is double the prescribed dosage. Choice B is incorrect as 6 tablets would be 1500mg, which is higher than the prescribed dosage. Choice D is incorrect as 2 tablets would only be 500mg, which is lower than the prescribed dosage.