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Questions 158

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Question 1 of 5

The client is admitted with a diagnosis of chorioamnionitis. Which vital sign change is most likely to be observed?

Correct Answer: D

Rationale: Chorioamnionitis causes maternal fever (from infection) tachycardia (from systemic response) and fetal bradycardia (from distress). All vital sign changes are likely in this condition.

Question 2 of 5

A client with angina is experiencing migraine headaches. The physician has prescribed Sumatriptan succinate (Imitrex). Which nursing action is most appropriate?

Correct Answer: A

Rationale: Sumatriptan, a triptan, is contraindicated in angina due to vasoconstrictive effects, risking coronary ischemia. Questioning the order (
A) is priority. Samples (
B), teaching (
C), and financial aid (
D) are inappropriate without resolving the contraindication.

Question 3 of 5

Four days after admission for cirrhosis of the liver, the nurse observes the following when assessing a male client: increased irritability, asterixis, and changes in his speech pattern. Which of the following foods would be appropriate for his bedtime snack?

Correct Answer: B

Rationale: While fresh fruit is low in protein, a milkshake is a better choice as it provides carbohydrates and some protein in a form that is easier to digest, which is crucial for clients with cirrhosis to avoid ammonia buildup. A milkshake is appropriate as it provides carbohydrates, which are needed to prevent protein catabolism, and has lower protein content compared to options like peanut butter or ham, reducing the risk of ammonia accumulation. (C,
D) Both saltine crackers with peanut butter and a ham and cheese sandwich are high in protein, which can increase ammonia levels, exacerbating hepatic encephalopathy.

Question 4 of 5

A client with a history of Addison's disease is admitted with complaints of nausea and vomiting. The nurse should expect the client to have:

Correct Answer: A

Rationale: Addison's disease causes adrenal insufficiency, reducing aldosterone, which leads to hyperkalemia due to impaired potassium excretion.

Question 5 of 5

Which of the following serum laboratory values would the nurse monitor during gentamicin therapy?

Correct Answer: A

Rationale: A common side effect of gentamicin is nephrotoxicity. The serum laboratory test that best reflects kidney function is serum creatinine.

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