Nokea
The physician has ordered Dilantin (phenytoin) for a client with generalized seizures. When planning the client's care the nurse should:
- A. Maintain strict intake and output
- B. Check the pulse before giving the medication
- C. Administer the medication 30 minutes before meals
- D. Provide oral hygiene and gum care every shift
Correct Answer: D
Rationale: Dilantin can cause gingival hyperplasia, so oral hygiene and gum care are essential to prevent complications.
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The nurse is caring for a client with systemic lupus erythematosis (SLE). The major complication associated with systemic lupus erythematosis is:
- A. Nephritis
- B. Cardiomegaly
- C. Desquamation
- D. Meningitis
Correct Answer: A
Rationale: Nephritis is the major complication of SLE due to immune complex deposition in the kidneys, leading to lupus nephritis, which can cause renal failure if untreated.
The physician has prescribed rantidine (Zantac) for a client with erosive gastritis. The nurse should administer the medication:
- A. 30 minutes before meals
- B. With each meal
- C. In a single dose at bedtime
- D. 60 minutes after meals
Correct Answer: C
Rationale: Ranitidine is most effective when taken at bedtime to suppress nocturnal acid production in erosive gastritis.
Shortly after the client was admitted to the postpartum unit, the nurse notes heavy lochia rubra with large clots. The nurse should anticipate an order for:
- A. Methergine
- B. Stadol
- C. Magnesium sulfate
- D. Phenergan
Correct Answer: A
Rationale: Methergine promotes uterine contractions to control postpartum hemorrhage, indicated for heavy lochia with clots.
After the physician performs an amniotomy, the nurse's first action should be to assess the:
- A. Degree of cervical dilation
- B. Fetal heart tones
- C. Client's vital signs
- D. Client's level of discomfort
Correct Answer: B
Rationale: Post-amniotomy, assessing fetal heart tones is critical to detect potential cord prolapse or distress.
A client in ICU is being closely monitored after a fall. The nurse notices a slight increase in intracranial pressure (ICP). The nurse should intervene by
- A. increasing oxygen flow.
- B. elevating the head of the bed to 90 degrees.
- C. turning and repositioning the patient on his side.
- D. suctioning the patient at least hourly.
Correct Answer: C
Rationale: Turning and repositioning the patient helps reduce ICP by promoting venous drainage. Elevating the head to 30-45 degrees (not 90) is appropriate; excessive suctioning or oxygen changes may not address ICP directly.