Nokea
When a woman is receiving postpartum epidural morphine, the nurse should plan to observe for which of the following side effects to occur within the first 3 hours?
- A. nausea and vomiting
- B. itching
- C. urinary retention
- D. somnolence
Correct Answer: B
Rationale: A side effect of postpartum epidural morphine is the onset of itching within 3 hours of injection and lasting up to 10 hours. Nausea and vomiting might occur 4-7 hours after injection. Urinary retention is a side effect of postpartum epidural morphine but is not assessed as such within the first 3 hours. Somnolence is a rare side effect.
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Which of the following client groups should the nurse recognize as the fastest-growing segment of the homeless population?
- A. single, adult men
- B. single mothers with 2 or 3 children
- C. runaway adolescents
- D. single, adult women
Correct Answer: B
Rationale: Single mothers with two or three children are indeed the fastest-growing segment of the homeless population. These families, where the majority of children are under the age of five, make up more than one-third of the homeless population in the United States. While single, adult men have traditionally been the largest group in the homeless population, single mothers with children have been increasing in numbers. Runaway adolescents, although a significant group of homeless children, do not represent the fastest-growing segment of the homeless population. Single, adult women are not specified as the fastest-growing segment.
A client who was given a diagnosis of hypertension 3 months ago is at the clinic for a checkup. Which type of database does the nurse use in performing an assessment?
- A. Emergency
- B. Follow-up
- C. Complete (total)
- D. Problem-centered
Correct Answer: B
Rationale: The correct answer is 'Follow-up.' A follow-up database is used to assess the status of an identified problem at regular intervals. An emergency database is for urgent data collection during life-saving measures. A complete database involves a full health history and physical examination. A problem-centered (episodic) database focuses on a limited or short-term issue, typically centered around one problem or body system.
During a voice test, how should the nurse provide words for the client to repeat?
- A. Spoken in a soft tone of voice by the nurse about 5 feet in front of the client
- B. Whispered by the nurse from the client's side at a distance of 1 to 2 feet from the ear being tested
- C. Spoken by the nurse from the client's side in a normal tone of voice about 10 feet from the ear being tested
- D. Whispered at a distance of 20 feet by the nurse while he or she is standing in front of the client
Correct Answer: B
Rationale: During a voice test, the nurse should whisper words from the client's side at a distance of 1 to 2 feet from the ear being tested. This distance helps prevent transmission around the head and ensures accurate testing of one ear at a time. By standing close to the client and whispering, the nurse prevents lip-reading and compensatory actions by the client. The client with normal hearing should be able to repeat each word correctly. Choices A, C, and D are incorrect. Choice A is wrong as the voice should be whispered, not spoken in a soft tone. Choice C is inaccurate because a distance of 10 feet is too far for precise testing. Choice D is incorrect as whispering from a distance of 20 feet would not effectively test the client's hearing.
A healthcare provider is assisting with data collection on a client for the major risk factors associated with coronary artery disease (CAD). Which modifiable risk factor does the healthcare provider obtain data on from the client?
- A. Age
- B. Ethnicity
- C. Hypertension
- D. Genetic inheritance
Correct Answer: C
Rationale: The correct answer is 'Hypertension.' Risk factors for CAD are categorized as modifiable and unmodifiable. Unmodifiable risk factors include age, sex, ethnicity, genetic predisposition, and family history of heart disease. Modifiable risk factors include increased concentrations of serum lipids, hypertension, cigarette smoking, obesity, and level of physical activity. In this case, hypertension is a modifiable risk factor that the healthcare provider would obtain data on. Choices A, B, and D are incorrect because age, ethnicity, and genetic inheritance are unmodifiable risk factors for CAD, not modifiable ones.
What classification of drug is Diltiazem?
- A. Calcium-Channel Blocker
- B. NSAID
- C. ACE Inhibitor
- D. Beta-Blocker
Correct Answer: A
Rationale: Diltiazem belongs to the class of calcium-channel blockers, not NSAIDs, ACE Inhibitors, or Beta-Blockers. Calcium-channel blockers like Diltiazem are used to treat conditions such as hypertension by relaxing blood vessels and increasing the supply of blood and oxygen to the heart. Therefore, the correct classification for Diltiazem is a Calcium-Channel Blocker. NSAIDs, ACE Inhibitors, and Beta-Blockers belong to different classes of drugs with distinct mechanisms of action and therapeutic uses, making them incorrect choices for Diltiazem.