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Question 1 of 5

A client returns for her 6-month prenatal checkup and has gained 10 lb in 2 months. The results of her physical examination are normal. How does the nurse interpret the effectiveness of the instruction about diet and weight control?

Correct Answer: B

Rationale: She is probably not compliant with her diet and exercise program. Recommended weight gain during second and third trimesters is approximately 12 lb. Because of her excessive weight gain of 10 lb in 2 months, she needs re-evaluation of her eating habits and reinforcement of proper dietary habits for pregnancy. A 2200-calorie diet is recommended for most pregnant women with a weight gain of 27-30 lb over the 9-month period. With rapid and excessive weight gain, PIH should also be suspected. She does not need to increase her caloric intake, but she does need to re-evaluate dietary habits. Ten pounds in 2 months is excessive weight gain during pregnancy, and health teaching is warranted. Restrictive dieting is not recommended during pregnancy.

Question 2 of 5

Which of the following nursing care goals has the highest priority for a child with epiglottitis?

Correct Answer: A

Rationale: Of these four goals, maintenance of a calm, quiet atmosphere to reduce anxiety and to allow for rest is the most important. Although nutrition is important, the child needs fluids to maintain fluid and electrolyte balance more than solid foods. In addition, the child may not be able to swallow solid foods owing to epiglottic swelling. This goal is unrealistic because fever is a common symptom of the infection associated with epiglottitis. If overexerted, the child will need more O2 and energy than available, and these requirements may exacerbate the condition.

Question 3 of 5

A client with B negative blood requires a blood transfusion during surgery. If no B negative blood is available, the client should be transfused with:

Correct Answer: C

Rationale: O negative blood is the universal donor type, safe for all recipients, including B negative, as it lacks A, B, and Rh antigens, minimizing transfusion reactions.

Question 4 of 5

Azulfidine (Sulfasalazine) may be ordered for a client who has ulcerative colitis. Which of the following is a nursing implication for this drug?

Correct Answer: C

Rationale: Sulfasalazine commonly causes skin rash and diarrhea, which should be monitored. The other options are not relevant nursing implications.

Question 5 of 5

A client with a history of a tonsillectomy is being discharged. The nurse should teach the client to:

Correct Answer: C

Rationale: Excessive swallowing post-tonsillectomy may indicate bleeding, a serious complication requiring immediate reporting. Gargling, cold liquids, and straws may irritate the surgical site.

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