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Questions 158

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Extract:


Question 1 of 5

The nurse is caring for a client with a diagnosis of gestational hypertension. Which complication is most likely to occur?

Correct Answer: A

Rationale: Gestational hypertension can progress to preeclampsia characterized by proteinuria and other systemic symptoms and is the most likely complication. Preterm labor and macrosomia are less directly related.

Question 2 of 5

The nurse is assisting in the care of a patient who is two days post-operative from a hemorrhoidectomy. The nurse would be correct in instructing the patient to:

Correct Answer: D

Rationale: Sitz baths after bowel movements promote healing and relieve pain post-hemorrhoidectomy by keeping the area clean and reducing inflammation. High-fiber diets are encouraged, ice packs are typically used earlier, and laxatives may be prescribed but are not the priority.

Question 3 of 5

The nurse is teaching a client with a history of migraines about trigger avoidance. The nurse should tell the client to avoid:

Correct Answer: A

Rationale: Chocolate is a common migraine trigger, potentially causing vasoconstriction or neurotransmitter changes, so it should be avoided.

Question 4 of 5

A premature infant needs supplemental O2 therapy. A nursing intervention that reduces the risk of retrolental fibroplasia is to:

Correct Answer: A

Rationale: Maintaining O2 at <40% minimizes the risk of retrolental fibroplasia, a complication of high oxygen levels in premature infants.

Question 5 of 5

A client develops an intestinal obstruction postoperatively. A nasogastric tube is attached to low, intermittent suction with orders to 'Irrigate NG tube with sterile saline q1h and prn.' The rationale for using sterile saline, as opposed to using sterile water to irrigate the NG tube is:

Correct Answer: A

Rationale: Water is a hypotonic solution and will deplete electrolytes and cause metabolic acidosis when used for nasogastric irrigation. Irrigating with saline does not cause abdominal discomfort. Severe, colicky abdominal pain is a symptom of intestinal obstruction. Irrigating with water will not cause restlessness or insomnia in the postoperative client. Restlessness and insomnia can be emotional complications of surgery. A nasogastric tube placed in the stomach is used to decompress the bowel. Irrigating with saline ensures a patent, well-functioning tube. Irrigating with saline will not increase peristalsis.

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