Nokea
The nurse is transferring a client who is G4 P3 at 25 weeks' gestation with preeclampsia from the obstetrical intensive care unit to the antenatal unit. To safely manage this preeclamptic client, what should be included in the transfer report about this client? Select all that apply.
- A. Record of blood pressure trends
- B. Record of urine protein
- C. Edema observed by health care provider
- D. Client use of dietary sodium
- E. Fetal position
- F. Fetal heart rate pattern
Correct Answer: A,B,C,E,F,G
Rationale: For a client with preeclampsia, the transfer report should include blood pressure trends, urine protein levels, edema observations, fetal position, fetal heart rate patterns, and medical/nursing interventions, as these are critical for monitoring maternal and fetal status. Dietary sodium use is less critical unless specifically restricted.
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A client with a history of breast cancer is admitted with bone metastases. The nurse should include which of the following in the plan of care?
- A. Administer bisphosphonates as prescribed.
- B. Restrict calcium intake.
- C. Encourage bed rest.
- D. Apply cold packs to affected areas.
Correct Answer: A
Rationale: Bisphosphonates reduce bone resorption and pain in bone metastases.
A client diagnosed with glomerulonephritis and at risk of developing acute kidney injury should be monitored for which complication?
- A. Bradycardia
- B. Hypertension
- C. Decreased cardiac output
- D. Decreased central venous pressure
Correct Answer: B
Rationale: Acute kidney injury caused by glomerulonephritis is classified as intrinsic or intrarenal failure. This form of acute kidney injury is commonly manifested by hypertension, tachycardia, oliguria, lethargy, edema, and other signs of fluid overload. Acute kidney injury from prerenal causes is characterized by decreased blood pressure or a recent history of the same, tachycardia, and decreased cardiac output and central venous pressure. Bradycardia is not part of the clinical picture for renal failure.
The nurse is caring for a client with a history of heart failure who is receiving carvedilol (Coreg). The nurse should monitor the client for which of the following adverse effects?
- A. Bradycardia.
- B. Hyperglycemia.
- C. Hypertension.
- D. Weight loss.
Correct Answer: A
Rationale: Carvedilol, a beta-blocker, can cause bradycardia, requiring heart rate monitoring.
Select all of the cranial nerves that are accurately paired with its distinguishing characteristics and description. Again, select all that apply.
- A. Olfactory Cranial Nerve: The sensory nerve that transmits the sense of smell to the olfactory foramina of the nose
- B. Optic Cranial Nerve: This sensory nerve transmits the sense of vision from the retina to the brain.
- C. Oculomotor Cranial Nerve: This motor and sensory nerve controls eye movements and visual acuity.
- D. Trochlear Cranial Nerve: This motor nerve innervates eye ball movement and the superior oblique muscle of the eyes.
- E. Abducens Cranial Nerve: This motor nerve innervates and controls the abduction of the eye using the lateral rectus muscle.
- F. Facial Cranial Nerve: This motor nerve controls facial movements, some salivary glands and gustatory sensations from the anterior part of the tongue.
- G. Glossopharyngeal Cranial Nerve: This sensory nerve This nerve gives us the sense of taste from the posterior tongue, and it also innervates the parotid glands
Correct Answer: A,B,D,E,F
Rationale: Options A, B, D, E, and F are correct. The olfactory nerve (I) is sensory for smell, the optic nerve (II) is sensory for vision, the trochlear nerve (IV) is motor for the superior oblique muscle, the abducens nerve (VI) is motor for the lateral rectus muscle, and the facial nerve (VII) is both motor and sensory, controlling facial movements and taste from the anterior tongue. Option C is incorrect because the oculomotor nerve (III) does not control visual acuity, and option G is incorrect because the glossopharyngeal nerve (IX) is both sensory and motor, not purely sensory.
A client with Parkinson's disease is prescribed levodopa-carbidopa (Sinemet). The nurse should instruct the client to:
- A. Take the medication on an empty stomach.
- B. Avoid vitamin B6 supplements.
- C. Take the medication with a high-protein meal.
- D. Stop the medication if dizziness occurs.
Correct Answer: B
Rationale: Vitamin B6 can reduce the effectiveness of levodopa, so clients should avoid B6 supplements.