Nokea
Your pregnant client has a new order for a medication. What principle should you apply to this new medication?
- A. The fact that drugs classified as categories C, D and X are contraindicated for women who are pregnant.
- B. The fact that drugs classified as categories A, B and C are contraindicated for women who are pregnant.
- C. The fact that drugs classified as categories C, D and E are contraindicated for women who are pregnant.
- D. The fact that drugs classified as categories C, D and Z are contraindicated for women who are pregnant.
Correct Answer: A
Rationale: Drugs in FDA pregnancy categories C, D, and X carry risks (potential harm, known harm, or absolute contraindication, respectively) and are generally contraindicated in pregnancy unless benefits outweigh risks.
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The nurse is teaching a client with a new colostomy about dietary choices. Which of the following foods should the nurse recommend to prevent odor and gas?
- A. Yogurt.
- B. Broccoli.
- C. Cabbage.
- D. Beans.
Correct Answer: A
Rationale: Yogurt contains probiotics that can reduce gas and odor in colostomy output, unlike broccoli, cabbage, or beans.
Which statement about total parenteral nutrition is true?
- A. Clients are at high risk for infection when they are getting TPN because they are immunocompromised.
- B. Clients are at high risk for hyperglycemia when they are getting TPN because they are diabetic.
- C. The client should perform the Valsalva maneuver when the nurse changes the TPN tubing.
- D. The client should perform the Valsalva maneuver when the nurse changes the TPN dressing.
Correct Answer: C
Rationale: The Valsalva maneuver is used when changing TPN tubing to prevent air embolism by increasing intrathoracic pressure.
A client has had a cardiac catheterization. The left femoral dressing has a moderate amount of bloody drainage, and the client has severe pain in that area. The nurse should first:
- A. Assess the airway.
- B. Administer oxygen.
- C. Apply pressure to the site.
- D. Assess the pulse in the left extremity.
Correct Answer: C
Rationale: Applying pressure to the site controls bleeding, which is the priority in this scenario.
The administration of an intramuscular injection to a neonate should be given in the:
- A. Gluteus maximus muscle.
- B. Vastus lateralis muscle.
- C. Deltoid muscle.
- D. The sternocleidomastoid muscle.
Correct Answer: B
Rationale: The vastus lateralis is the preferred site for IM injections in neonates due to its large muscle mass and minimal risk of nerve or bone injury.
The nurse is informed that a newborn infant with Apgar scores of 1 and 4 will be brought to the nursery. The nurse determines that which intervention is the priority?
- A. Connecting the resuscitation bag to oxygen
- B. Turning on the apnea and cardiorespiratory monitor
- C. Preparing for the insertion of an intravenous (IV) line with D5W
- D. Setting up the radiant warmer control temperature at 36.5°C (97.6°F)
Correct Answer: A
Rationale: The top priority action for a newborn infant with low Apgar scores is maintaining a patent airway, which would involve preparing respiratory resuscitation equipment. Although the remaining options are also important, they are of lower priority. The newborn infant's cardiopulmonary status would be monitored by a cardiorespiratory monitoring device. Setting up an IV with D5W would provide circulatory support. The radiant warmer will provide an external heat source, which is necessary to prevent further respiratory distress.