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Questions 158

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Question 1 of 5

Seven days ago, a 45-year-old female client had an ileostomy. She is self-sufficient and well otherwise. Which of the following long-term objectives would be unrealistic?

Correct Answer: A

Rationale: Because of the location of an ileostomy, the client will not be able to control the evacuation of her bowels. The ileostomy will drain liquid stool continuously. The client should be able to return to a normal, well-balanced diet. She should avoid foods that cause diarrhea or excessive gas production, and she should eat small meals. The client should be able to resume sexual activity. She will be able to wear a pouch. The client has no other health or mental problems and should be able to manage her own ileostomy.

Question 2 of 5

Which medication does the nurse expect to be ordered for the postpartal patient with bleeding uncontrolled by Pitocin (oxytocin)?

Correct Answer: A

Rationale: Methergine is used to treat postpartum hemorrhage unresponsive to Pitocin by promoting uterine contractions. Aquamephyton is for clotting, Amicar is for fibrinolysis, and Celestone is a corticosteroid, none of which address uterine bleeding.

Question 3 of 5

Which of the following signs might indicate a complication during the labor process with vertex presentation?

Correct Answer: D

Rationale: Fetal tachycardia may indicate fetal hypoxia; however, 170 bpm is only mild tachycardia. Nausea and vomiting occur frequently during transition and are not a complication. Contractions frequently last 60-90 seconds during the transitional phase of labor and are not considered a complication as long as the uterus relaxes completely between contractions. Passage of meconium in a vertex presentation is a sign of fetal distress; this may be normal in a breech presentation owing to pressure on the presenting part.

Question 4 of 5

A client with benign prostatic hypertrophy has been started on Proscar (finasteride). The nurse's discharge teaching should include:

Correct Answer: A

Rationale: Finasteride tablets should not be handled by pregnant women due to the risk of fetal harm. Symptom improvement takes months, not weeks, and the medication can be taken with or without food or at any time.

Question 5 of 5

The nurse is caring for a 6-week-old girl with meningitis. To help her develop a sense of trust, the nurse should:

Correct Answer: D

Rationale: A soft blanket may be comforting, but it is not directed toward developing a sense of trust. Good perineal care is important, but it is not directed toward developing a sense of trust. An infant with meningitis needs frequent attention, but leaving the door open does not foster trust. Consistently picking her up when she cries will help the child feel trust in her caregivers.

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