Nokea
When administering phenytoin (Dilantin) to a child, the nurse should be aware that a toxic effect of phenytoin therapy is:
- A. Stephens-Johnson syndrome
- B. Folate deficiency
- C. Leukopenic aplastic anemia
- D. Granulocytosis and nephrosis
Correct Answer: A
Rationale: Stephens-Johnson syndrome is a toxic effect of phenytoin. Folate deficiency is a side effect of phenytoin, but not a toxic effect. Leukopenic aplastic anemia is a toxic effect of carbamazepine (Tegretol). Granulocytosis and nephrosis are toxic effects of trimethadione (Tridione).
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The nurse is teaching a group of prenatal clients about the effects of cigarette smoke on fetal development. Which characteristic is associated with babies born to mothers who smoked during pregnancy?
- A. Low birth weight
- B. Large for gestational age
- C. Preterm birth,but appropriate size for gestation
- D. Growth retardation in weight and length
Correct Answer: A
Rationale: Smoking during pregnancy restricts placental blood flow leading to low birth weight. Babies are not typically large and while preterm birth or growth retardation may occur low birth weight is the most consistent finding.
A 22-year-old client is 16 weeks pregnant. She and her husband are expecting their first baby. The client tells the nurse that her last normal menstrual period was February 16, with 3 days of spotting on February 17, 18, and 19. The nurse calculates her expected date of delivery to be:
- A. November 23rd
- B. December 26th
- C. September 14th
- D. December 9th
Correct Answer: A
Rationale: Naegele's rule is as follows: add 7 days to the 1st day of the last menstrual period, subtract 3 months, and then add 1 year. Naegele's rule presumes that the woman has a 28-day menstrual cycle, with conception occurring on the 14th day of the cycle. Slight vaginal spotting may occur in early gestation for unknown reasons but is insignificant in the calculation of Naegele's rule. Naegele's rule presumes that the woman has a 28-day menstrual cycle, with conception occurring on the 14th day of the cycle. Slight vaginal spotting may occur in early gestation for unknown reasons but is insignificant in the calculation of Naegele's rule. Naegele's rule presumes that the woman has a 28-day menstrual cycle, with conception occurring on the 14th day of the cycle. Slight vaginal spotting may occur in early gestation for unknown reasons but is insignificant in the calculation of Naegele's rule.
A client is admitted with suspected acute pancreatitis. Which lab finding confirms the diagnosis?
- A. Blood glucose of 260 mg/dL
- B. White cell count of 21,000 cu/mm
- C. Platelet count of 250,000 cu/mm
- D. Serum amylase level of 600 units/dL
Correct Answer: D
Rationale: Elevated serum amylase (typically >3 times normal) is a key diagnostic marker for acute pancreatitis due to pancreatic enzyme leakage. The other findings are nonspecific or normal.
A physician's order reads: Administer KCl 10% oral solution 1.5 mL. The KCl bottle reads 20 mEq/15 mL. What dosage should the nurse administer to the infant?
- A. 1 mEq
- B. 1.13 mEq
- C. 2 mEq
- D. 3 mEq
Correct Answer: C
Rationale: 1.33 mEq = 1 mL, then 1.5 mL X = 1.99, or 2 mEq.
A client is being discharged and will continue enteral feedings at home. Which of the following statements by a family member indicates the need for further teaching?
- A. If he develops diarrhea lasting for more than 2-3 days, I will contact the doctor or nurse.
- B. I should anticipate that he will gain about 1 lb/day now that he is on continuous feedings.
- C. It is important to keep the head of his bed elevated or sit him in the chair during feedings.
- D. I should use prepared or open formula within 24 hours and store unused portions in the refrigerator.
Correct Answer: B
Rationale: Diarrhea is a complication of tube feedings that can lead to dehydration. Diarrhea may be the result of hypertonic formulas that can draw fluid into the bowel. Other causes of diarrhea may be bacterial contamination, fecal impaction, medications, and low albumin. A consistent weight gain of more than 0.22 kg/day (1/2 lb/day) over several days should be reported promptly. The client should be evaluated for fluid volume excess. Elevating the client's head prevents reflux and thus formula from entering the airway. Bacteria proliferate rapidly in enteral formulas and can cause gastroenteritis and even sepsis.