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Questions 158

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Question 1 of 5

In assessing cardiovascular clients with progression of aortic stenosis, the nurse should be aware that there is typically:

Correct Answer: D

Rationale: These signs are seen in pulmonic stenosis or in response to pulmonary congestion and edema and mitral stenosis. These signs are seen primarily in mitral stenosis or as a late sign in aortic stenosis after left ventricular failure. These signs are seen primarily in right-sided heart valve dysfunction. Left ventricular hypertrophy occurs to increase muscle mass and overcome the stenosis; left ventricular pressures increase as left ventricular volume increases owing to insufficient emptying.

Question 2 of 5

The nurse is caring for a client with a diagnosis of placenta accreta. Which intervention is most appropriate?

Correct Answer: A

Rationale: Placenta accreta often prevents placental separation leading to severe hemorrhage during delivery which may necessitate hysterectomy.
Tocolytics fetal monitoring and antibiotics are not primary interventions for this condition.

Question 3 of 5

The physician has ordered an intravenous infusion of Pitocin for the induction of labor. When caring for the obstetric client receiving intravenous Pitocin,the nurse should monitor for:

Correct Answer: B

Rationale: Pitocin (oxytocin) can cause uterine hyperstimulation leading to reduced placental perfusion and fetal bradycardia (heart rate <110 bpm). Monitoring for fetal bradycardia is critical. Hypoglycemia hyperreflexia and fetal movement frequency are not directly related to Pitocin complications.

Question 4 of 5

An elderly client refuses to take her daily medication for hypertension. Which action should the nurse take at this time?

Correct Answer: D

Rationale: Exploring the reason for the client’s refusal respects autonomy and may reveal misunderstandings, fears, or side effects that can be addressed. Administering by injection or with help violates autonomy, and skipping the dose delays treatment without addressing the issue.

Question 5 of 5

The nurse is caring for a client following a myocardial infarction. Which of the following enzymes are specific to cardiac damage?

Correct Answer: C

Rationale: CK-MB and LDH are specific to cardiac damage, with CK-MB being highly specific for myocardial infarction due to its presence in heart muscle.

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