The Expecting Mother
A nurse is assessing a client who is pregnant for preeclampsia. Which of the following findings should indicate to the nurse that the client requires further evaluation for this disorder?
Elevated blood pressure
Answer Rationale:
Hypertension is one of the cardinal symptoms of preeclampsia, along with excessive weight gain, edema, and albumin in the urine.
A nurse is caring for a client who has liver cirrhosis with ascites, bleeding esophageal varices, and portal hypertension. The nurse recognizes which of the following laboratory findings as indicating the client’s gastrointestinal (GI) tract is digesting and absorbing blood?
Elevated blood urea nitrogen (BUN)
Answer Rationale:
As the body digests blood, BUN rises. An elevated BUN is an indication of GI bleeding.
A nurse is assessing a toddler who has heart failure. Which of the following findings should the nurse expect?
Orthopnea
Answer Rationale:
A toddler who has heart failure has increased venous return to the heart and lungs, which leads to pulmonary congestion. The congestion causes orthopnea, or difficulty breathing, while lying down. Having the toddler sit up decreases venous return, as well as pressure the abdominal organs have on the diaphragm. This decrease in pressure improves breathing and oxygenation.
A nurse is assessing a client who is receiving dopamine IV to treat left ventricular failure. Which of the following findings should indicate to the nurse that the medication is having a therapeutic effect?
Systolic blood pressure is increased
Answer Rationale:
When dopamine has a therapeutic effect, it causes vasoconstriction peripherally and increases systolic blood pressure.
A nurse is planning care for a client who requires screening for rectal cancer. Which of the following tests should the nurse anticipate in the client's plan of care?
Colonoscopy
A nurse in the antepartum unit is caring for a client who is at 36 weeks of gestation and has pregnancy-induced hypertension. Suddenly, the client reports continuous abdominal pain and vaginal bleeding. The nurse should suspect which of the following complications?
Abruptio placentae
Answer Rationale:
The classic signs of abruptio placentae include vaginal bleeding, abdominal pain, uterine tenderness, and contractions.
A nurse is completing a medical interview with a client who has elevated cholesterol levels and takes warfarin. The nurse should recognize that which of the following actions by the client can potentiate the effects of warfarin?
A nurse is completing a medical interview with a client who has elevated cholesterol levels and takes warfarin. The nurse should recognize that which of the following actions by the client can potentiate the effects of warfarin?
A nurse is teaching a parent of an infant who has heart failure about meeting the infant's nutritional needs. Which of the following statements by the parent indicates an understanding of the teaching?
"I will add Polycose to each of my baby's bottles."
Answer Rationale:
The parent should add Polycose to the formula to increase the number of calories per ounce, allowing the infant to consume more calories in less volume.
A nurse is caring for an adolescent who has hemophilia A and is scheduled for wisdom teeth extractions. Prior to the procedure, the nurse should anticipate that the client will receive which of the following products?
Recombinant
Answer Rationale:
The underlying problem of hemophilia is a deficiency of clotting factors. Therefore, clients who have hemophilia are given recombinant to replace the deficient factor as a prophylactic measure before an invasive procedure, surgery, or when actively bleeding.
A nurse is providing teaching to a client who has a superficial lesion and has had a biopsy indicates malignant melanoma. The nurse should include which of the following options as the treatment of choice?
Surgical excision
Answer Rationale:
Surgical excision is the treatment of choice for superficial lesions of malignant melanoma.