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Question 1 of 5

A 28-year-old multigravida has class II heart disease. At her prenatal visit at 34 weeks' gestation, all of the following observations are made. Which would require intervention?

Correct Answer: C

Rationale: This is not an excessive weight gain indicative of fluid retention. The blood pressure is within normal range. Showering should not cause shortness of breath. This could be a sign of cardiac decompensation. Dependent ankle edema is normal late in the day among pregnant women. Progressive edema would be a dangerous development.

Question 2 of 5

The nurse is teaching a client with a history of hypertension about lifestyle modifications. The nurse should tell the client to:

Correct Answer: A

Rationale: Reducing stress lowers blood pressure in hypertension, improving cardiovascular health.

Question 3 of 5

A client with a history of a fractured femur is in skeletal traction. The nurse should:

Correct Answer: B

Rationale: Cleaning pin sites with saline (or per protocol) prevents infection in skeletal traction. Turning is limited, lotion is unnecessary, and removing weights disrupts traction.

Question 4 of 5

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:

Correct Answer: A

Rationale: Tamoxifen, an anti-estrogen, commonly causes hot flashes due to hormonal changes. Blood pressure, appetite, and hair loss are not primary side effects.

Question 5 of 5

The nurse is caring for a client with pancreatitis. Which of the following IV medications would the nurse expect the physician to prescribe for control of pain in this client?

Correct Answer: D

Rationale: Meperidine is the drug of choice for clients with pancreatitis. It will not cause spasms at the sphincter of Oddi, which can lead to increased pancreatic pain.

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