Nokea
The physician has ordered an intravenous infusion of Pitocin for the induction of labor. When assessing the client’s response to the Pitocin, the nurse should give priority to:
- A. Monitoring the blood pressure
- B. Checking the fetal heart rate
- C. Timing the frequency of contractions
- D. Assessing the urinary output
Correct Answer: B
Rationale: Pitocin can cause uterine hyperstimulation, risking fetal distress. Checking the fetal heart rate is the priority to ensure fetal well-being. Blood pressure, contractions, and urinary output are monitored but are secondary to fetal status.
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The nurse is caring for a client with pneumonia who is allergic to penicillin. Which antibiotic is safest to administer to this client?
- A. Cefazolin (Ancef)
- B. Amoxicillin
- C. Erythrocin (Erythromycin)
- D. Ceftriaxone (Rocephin)
Correct Answer: C
Rationale: Erythromycin, a macrolide, is safe for penicillin-allergic patients. Cefazolin (A), Amoxicillin (B), and Ceftriaxone (D) are beta-lactams with cross-reactivity risks.
The nurse is caring for a child in a plaster-of-Paris hip spica cast. To facilitate drying, the nurse should:
- A. Use a small hand-held hair dryer set on medium heat.
- B. Place a small heater near the child's bed.
- C. Turn the child at least every two hours.
- D. Allow one side to dry before changing positions.
Correct Answer: C
Rationale: Turning the child every two hours ensures even drying of the cast and prevents pressure sores, promoting proper cast setting.
The nurse is teaching a client with a history of lactose intolerance about dietary modifications. The nurse should tell the client to avoid:
- A. Dairy products
- B. High-fiber foods
- C. Lean meats
- D. Fresh fruits
Correct Answer: A
Rationale: Dairy products contain lactose, which causes gastrointestinal symptoms in lactose intolerance, so they should be avoided.
The nurse is caring for a client with a history of systemic lupus erythematosus. The nurse should expect the client to have:
- A. Joint pain
- B. Tremors
- C. Visual loss
- D. Abdominal pain
Correct Answer: A
Rationale: Systemic lupus erythematosus causes autoimmune inflammation, commonly leading to joint pain and arthritis-like symptoms.
The nurse is caring for a client post-thyroidectomy. Which assessment finding requires immediate intervention?
- A. Mild incisional pain
- B. Tingling in the fingers
- C. Slight hoarseness
- D. Temperature of 99.5°F
Correct Answer: B
Rationale: Tingling in the fingers suggests hypocalcemia due to parathyroid gland damage, risking tetany or seizures, requiring immediate intervention. Pain (A), hoarseness (C), and mild fever (D) are expected post-op.