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Questions 149

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Question 1 of 5

A client has had 4 pregnancies. She experienced one miscarriage at 12 weeks, had one stillborn birth at 34 weeks, a healthy son at 38 weeks, and a healthy daughter at 40 weeks. How would the client's obstetric history be classified?

Correct Answer: D

Rationale: Gravida 4 (4 pregnancies), Para 2 (2 viable births at 38 and 40 weeks). Miscarriage and stillbirth count as pregnancies but not viable births.

Question 2 of 5

The nurse plans on administering a medication using the Z-track intramuscular technique. The nurse knows the following steps are required during the procedure. Select all that apply.

Correct Answer: A,C

Rationale: Z-track requires an air lock (
A) to seal medication and a new needle (
C) to prevent tracking. The needle is inserted at 90 degrees, not 45 (
D), and various muscles can be used (B is not mandatory).

Question 3 of 5

A client with myasthenia gravis is admitted in a cholinergic crisis. Signs of of cholinergic crisis include:

Correct Answer: A

Rationale: Cholinergic crisis, due to excessive acetylcholinesterase inhibitors, causes symptoms like constricted pupils and decreased blood pressure from parasympathetic overstimulation.

Question 4 of 5

A client who has been taking Coumadin (warfarin) was stabbed in the upper arm. His prothrombin time is over twice the normal amount. The nurse anticipates an order for

Correct Answer: A

Rationale: Elevated prothrombin time indicates excessive anticoagulation. Fresh frozen plasma provides clotting factors to reverse warfarin’s effect and control bleeding.

Question 5 of 5

Before administering a client's morning dose of Lanoxin (digoxin), the nurse checks the apical pulse rate and finds a rate of 54. The appropriate nursing intervention is to:

Correct Answer: C

Rationale: A pulse rate below 60 bpm is a contraindication for digoxin administration due to the risk of worsening bradycardia, so the nurse should withhold the dose and notify the physician.

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