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Questions 158

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Question 1 of 5

After the fetal activity test (nonstress test) is completed, the RN is looking at the test results on the monitor strip. The RN observes that the fetal heart accelerated 5 beats/min with each fetal movement. The accelerations lasted 15 seconds and occurred 3 times during the 20 minute test. The RN knows that these test results will be interpreted as:

Correct Answer: A

Rationale: A reactive nonstress test requires at least two accelerations of the fetal heart rate of at least 15 bpm, lasting 15 seconds, over a 20-minute period. The described results (5 bpm accelerations) do not meet the criteria, but the correct answer provided is A, indicating a possible error in the question's data. However, based on the provided answer, it is interpreted as reactive.

Question 2 of 5

A client who is 7 months pregnant is diagnosed with pyelonephritis. The nurse anticipates the physician ordering:

Correct Answer: C

Rationale: Ampicillin is a safe antibiotic for pyelonephritis in pregnancy, with no known teratogenic effects.

Question 3 of 5

The nurse is caring for a client with a history of a seizure disorder who is receiving Valproic acid (Depakote). The nurse should monitor the client for:

Correct Answer: A

Rationale: Valproic acid can cause hepatotoxicity, requiring monitoring of liver enzymes. Hypotension, hyperglycemia, and weight loss are not primary side effects.

Question 4 of 5

A client who was started on antipsychotic medication 2 weeks ago is preparing for discharge from the hospital. Compliance with the medication regimen is important despite the mild side effects encountered. In order to increase the likelihood of medication compliance, the nurse would:

Correct Answer: A

Rationale: This answer is correct. If the client is well informed about what reactions to expect from her medication, she is more likely to follow the treatment regimen. This answer is incorrect. There are many side effects that are reversible by medication, and these must be reported to the nurse or physician. There are also more severe side effects, such as neuroleptic malignant syndrome, characterized by fever, tachycardia, and diaphoresis, which can be life threatening. This answer is incorrect. There is no need for weekly blood tests if the drug regimen has been followed properly. This answer is incorrect. The client should continue the medication until the physician recommends any change in the drug regimen. Symptoms will usually reappear if medication is discontinued.

Question 5 of 5

The nurse is caring for a client with cancer of the pancreas. Which finding indicates involvement of the bile ducts?

Correct Answer: A

Rationale: Pancreatic cancer can obstruct bile ducts causing bilirubin buildup and dark urine (bilirubinuria). Petechiae indicate bleeding dark stools suggest GI bleeding and steatorrhea reflects fat malabsorption not bile duct involvement.

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