Nokea
A 32-year-old multipara is seen in the prenatal clinic. The nurse notes she is in her fifth month of pregnancy and has a weight gain of 14 pounds. The history indicates that prenatally the client was of average height and weight.
The nurse should advise the client that
- A. she has gained too much weight and her diet should be reevaluated.
- B. she has not gained enough weight and her diet should be reevaluated.
- C. her weight gain is appropriate and she should continue on her present diet.
- D. her weight gain indicates that she may have difficulties later in pregnancy.
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) excessive weight gain is >6.6 lb (3 kg)/month (2) inadequate weight gain is <2.2 lb (1 kg)/month (3) correct-weight gain 2-5 lb (2.5 kg) first trimester, 0.66-1.1 lb (0.5 kg) weekly in second and third trimester (4) not substantiated by information presented in question
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The nurse is working in a surgeon's office and talking with a client who is scheduled for surgery in two weeks. The nurse asks about medications and supplements the client may be taking. What medication(s) the client reports would be of most concern to the nurse? Select all that apply.
- A. Acetaminophen
- B. Ibuprofen
- C. Vitamin C
- D. Vitamin E
- E. Ginseng
- F. Vitamin B complex
Correct Answer: B,D,E
Rationale: Ibuprofen, Vitamin E, and ginseng increase bleeding risk, posing concerns for surgical hemostasis.
The nurse is caring for an adult who is taking digoxin (Lanoxin) 0.25 mg daily. Which comment by the client is of greatest concern to the nurse because the client is taking digoxin?
- A. I don't seem to have much of an appetite lately.'
- B. My energy level is not as high as it once was.'
- C. My pulse yesterday was 60.'
- D. I have a pain in my right foot.'
Correct Answer: C
Rationale: A pulse of 60 may indicate bradycardia, a potential sign of digoxin toxicity, requiring immediate assessment. Anorexia and fatigue are less specific, and foot pain is unrelated to digoxin.
In addition to routine vital signs, what should the nurse assess because the client had a lumbar laminectomy?
- A. Hand grasps
- B. Foot strength
- C. Ability to swallow
- D. Abdominal muscle strength
Correct Answer: B
Rationale: Lumbar laminectomy affects lower spine nerves; assessing foot strength evaluates neurological function in the legs. Hand grasps, swallowing, and abdominal strength are unrelated.
An adult is being discharged from the emergency room with instructions to apply a cold pack to his sprained ankle. The client asks why it is necessary to use a cold pack. The nurse replies that the cold pack will do which of the following?
- A. Keep the sprain from becoming a fracture
- B. Prevent bruising and ecchymosis from occurring
- C. Keep the client from developing a fever
- D. Help reduce swelling and pain
Correct Answer: D
Rationale: Cold packs reduce swelling and pain by constricting blood vessels and numbing the area, aiding sprain recovery. They don't prevent fractures, bruising, or fever.
A client recently diagnosed with insulin-dependent diabetes mellitus (IDDM). As part of the treatment plan, the client receives Humulin N 32 units and Humulin R 8 units each morning.
Which of the following actions, if performed by the client while preparing the morning insulin injection, would require an intervention by the nurse?
- A. After the client draws up 8 units of Humulin R, she adds Humulin N to the syringe for a total of 40 units.
- B. The client draws up 32 units of the clear insulin followed by 8 units of cloudy insulin for a total of 40 units.
- C. Initially, the client injects air into the Humulin N vial without drawing up any insulin.
- D. The client injects air into each bottle of insulin equal to the amount of insulin to be withdrawn.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) clear insulin always drawn up first (2) correct-Humulin R is clear and drawn up first, only 8 units are ordered, Humulin N is cloudy (3) allows you to withdraw medication later (4) allows you to withdraw medication later