Nokea
The nurse should recognize which of the following findings as a potential contraindication for using lavender?
- A. The client has a history of asthma
- B. The client takes furosemide twice daily
- C. The client has a history of alcohol use disorder
- D. The client takes vitamin C daily
Correct Answer: A
Rationale: The correct answer is A: The client has a history of asthma. Lavender can trigger asthma symptoms due to its volatile organic compounds. People with asthma may experience worsened symptoms or even asthma attacks when exposed to lavender. Asthma is a contraindication as it can lead to serious health complications.
Explanation for other choices:
B: The client takes furosemide twice daily - Furosemide is a diuretic and does not interact significantly with lavender.
C: The client has a history of alcohol use disorder - Alcohol use disorder does not directly contraindicate the use of lavender.
D: The client takes vitamin C daily - Vitamin C does not interact significantly with lavender.
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The nurse is reviewing the client's medical record. Select 4 findings that indicate a potential prenatal complication.
- A. Urine protein
- B. Fetal activity
- C. Blood pressure
- D. Urine ketones
- E. Respiratory rate
- F. Report of headache
- G. Gravida/parity
Correct Answer: A,C,F,G
Rationale: The correct answers (A, C, F, G) indicate potential prenatal complications. Urine protein (A) suggests preeclampsia, a serious condition characterized by high blood pressure (C) and proteinuria. Headaches (F) can also be a sign of preeclampsia. Gravida/parity (G) provides important obstetric history, identifying high-risk pregnancies. Fetal activity (B) and respiratory rate (E) are not specific to prenatal complications. Urine ketones (D) may indicate dehydration but not necessarily a prenatal complication.
A nurse is caring for a client whose child died from cancer. The client states 'it's hard to go on without him'. which of the following questions should the nurse ask the client first?
- A. What has helped you through difficult times in the past?
- B. Has anyone in your family committed suicide?
- C. Is there anyone you would like involved in your care?
- D. Are you thinking about ending your life?
Correct Answer: D
Rationale: The correct answer is D: Are you thinking about ending your life? This question is crucial as it directly addresses the client's statement about finding it hard to go on. It assesses the client's suicidal ideation and determines the level of risk for self-harm or suicide. It prioritizes the client's safety and well-being.
Choice A is incorrect because it does not directly address the immediate concern of potential suicide risk. Choice B is irrelevant and may lead to unnecessary distress for the client. Choice C is important but not as urgent as assessing for suicidal ideation.
Which of the following actions should the nurse plan to take?
- A. Place the clients head of bed flat
- B. apply heat to the client's abdomen
- C. keep the client on NPO status
- D. administer A laxative to the client
Correct Answer: C
Rationale: The correct answer is C: keep the client on NPO status. This is the correct action as it means "nothing by mouth," which is often necessary before certain medical procedures or surgeries to prevent aspiration. Choice A is incorrect as elevating the head of the bed reduces the risk of aspiration. Choice B is incorrect as heat application may not be indicated and could potentially worsen the client's condition. Choice D is incorrect as administering a laxative may not be appropriate without a proper assessment.
In anticipation of multiple client admissions, which of the following current clients should the nurse recommend for early discharge?
- A. A client who was one day postoperative following a vertebroplasty.
- B. A client receiving IV antibiotics for pneumonia with a fever of 101°F(38.3°C).
- C. A client who had a transient ischemic attack(TIA) 12 hours ago and is awaiting further evaluation.
- D. A client with uncontrolled atrial fibrillation requiring continuous cardiac monitoring.
Correct Answer: A
Rationale: The correct answer is A. The client one day postoperative following a vertebroplasty can be recommended for early discharge as this procedure is typically short-stay and does not require extended monitoring. The client is likely stable and can continue recovery at home.
Choice B is incorrect because a client with pneumonia and a fever of 101°F requires continued IV antibiotics and monitoring to ensure resolution of infection and fever reduction.
Choice C is incorrect as a client with a recent TIA requires further evaluation and monitoring to prevent recurrent strokes and assess for potential complications.
Choice D is incorrect because a client with uncontrolled atrial fibrillation requiring continuous cardiac monitoring should not be discharged early as they need close monitoring and management to prevent complications like stroke or heart failure.
The nurse is initiating the client's plan of care. Which of the following Interventions should the nurse plan to implement?
- A. Provide a low-stimulation environment.
- B. Maintain bed rest.
- C. Give antihypertensive medication.
- D. Administer betamethasone
- E. Monitor intake and output hourly.
- F. Obtain a 24 hr urine specimen.
- G. Perform a vaginal examination every 12 hr.
Correct Answer: A,B,C,D,E,F
Rationale: The correct answer includes providing a low-stimulation environment (A) for client comfort, maintaining bed rest (B) to promote healing, giving antihypertensive medication (C) for blood pressure management, administering betamethasone (D) for specific medical needs, monitoring intake and output hourly (E) for fluid balance assessment, and obtaining a 24 hr urine specimen (F) for diagnostic purposes. These interventions are essential in addressing the client's physical and physiological needs during care planning. Performing a vaginal examination every 12 hr (G) is not typically indicated and may not be necessary unless specifically ordered for a particular condition.