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Questions 158

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Question 1 of 5

A 30-year-old client in the third trimester of her pregnancy asks the nurse for advice about upper respiratory discomforts. She complains of nasal stuffiness and epistaxis, most noticeable on the left side. Which reply by the nurse is correct?

Correct Answer: C

Rationale: Decongestants may exaggerate the nasal stuffiness associated with pregnancy. Judicious use of decongestants and nasal sprays is advocated during pregnancy. Cool air vaporizers and saline drops may help to relieve the nasal stuffiness. Positioning on either lateral side does not decrease nasal stuffiness or prevent epistaxis. Increased estrogen levels result in nasal mucosa edema with subsequent nasal stuffiness. Estrogen also promotes vasodilation, which contributes to epistaxis. The nurse may recommend cool air vaporizers and saline drops to help with the nasal stuffiness. Increased estrogen levels result in nasal mucosa edema with subsequent nasal stuffiness. Estrogen also promotes vasodilation discomforts associated with pregnancy.

Question 2 of 5

The nurse is caring for a client with a diagnosis of chorioamnionitis. Which diagnostic test is most likely to be ordered?

Correct Answer: C

Rationale: Chorioamnionitis requires a complete blood count to assess for infection (e.g. elevated white blood cells) and amniotic fluid analysis to confirm infection. Both tests are commonly ordered.

Question 3 of 5

Which food selection would provide the most calcium for a client who is four months pregnant?

Correct Answer: C

Rationale: Yogurt is a rich source of calcium essential for fetal bone development during pregnancy. One cup provides approximately 300-400 mg of calcium significantly more than oatmeal bran muffins or oranges.

Question 4 of 5

Following a gastric resection, a 70-year-old client is admitted to the postanesthesia care unit. He was extubated prior to leaving the suite. On arrival at the postanesthesia care unit, the nurse should:

Correct Answer: A

Rationale: Adequate air exchange and tissue oxygenation depend on competent respiratory function. Checking the airway is the nurse's priority action. Obtaining the vital signs is an important action, but it is secondary to airway management. Reorienting a client to time, place, and person after surgery is important, but it is secondary to airway and vital signs. Airway management takes precedence over physician's orders unless they specifically relate to airway management.

Question 5 of 5

A client with angina is experiencing migraine headaches. The physician has prescribed Sumatriptan succinate (Imitrex). Which nursing action is most appropriate?

Correct Answer: A

Rationale: Sumatriptan, a triptan, is contraindicated in angina due to vasoconstrictive effects, risking coronary ischemia. Questioning the order (
A) is priority. Samples (
B), teaching (
C), and financial aid (
D) are inappropriate without resolving the contraindication.

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