Nokea
While assisting the physician with an amniocentesis on a multigravid client at 38 weeks' gestation, the nurse observes that the fluid is very cloudy and thick. The nurse interprets this finding as indicating which of the following?
- A. Intrauterine infection.
- B. Fetal meconium staining.
- C. Erythroblastosis fetalis.
- D. Normal amniotic fluid.
Correct Answer: B
Rationale: Cloudy, thick amniotic fluid often indicates meconium staining, suggesting fetal distress, which requires further evaluation.
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The nurse is teaching a client with a new diagnosis of gout about dietary management. Which of the following foods should the client include?
- A. Cherries.
- B. Red meat.
- C. Shellfish.
- D. Organ meats.
Correct Answer: A
Rationale: Cherries reduce uric acid levels and inflammation in gout.
A client is prescribed diphenhydramine 1% as a topical agent for allergic dermatosis. The nurse evaluates that the medication is having the intended effect when the client reports relief of what complaint?
- A. Pain
- B. Urticaria
- C. Headache
- D. Skin redness
Correct Answer: B
Rationale: Diphenhydramine is an antihistamine medication that has many uses. When used as a topical agent on the skin, it reduces the symptoms of allergic reaction, such as itching or urticaria. It does not act to relieve pain, headache, or skin redness.
The nurse is caring for a client with a history of breast cancer who is receiving tamoxifen (Nolvadex). The nurse should monitor the client for which of the following adverse effects?
- A. Endometrial cancer.
- B. Hypocalcemia.
- C. Alopecia.
- D. Weight loss.
Correct Answer: A
Rationale: Tamoxifen increases the risk of endometrial cancer, requiring monitoring for abnormal vaginal bleeding.
The nurse is caring for a client receiving chemotherapy. Which precaution is most important?
- A. Use standard precautions.
- B. Wear a gown and gloves.
- C. Place the client in isolation.
- D. Monitor for fever.
Correct Answer: D
Rationale: Monitoring for fever is critical, as chemotherapy increases infection risk due to immunosuppression.
Which sound should you expect to hear when you percuss the liver during a complete physical assessment?
- A. Resonance
- B. Flatness
- C. Tympany
- D. Dullness
Correct Answer: D
Rationale: The liver, a solid organ, produces a dull sound when percussed, as opposed to the tympanic sound of air-filled structures or the resonant sound of lung tissue.