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Questions 164

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Question 1 of 5

The nurse is caring for a pregnant woman with pregnancy induced hypertension (PIH) receiving magnesium sulfate intravenously. In assessing the client, it is noted that respirations are 12, pulse and blood pressure have dropped significantly, and 8 hour output is 200 ml. What should the nurse do first?

Correct Answer: C

Rationale: The assessments strongly suggest magnesium sulfate toxicity. The nurse must discontinue the IV immediately and take measures to ensure the safety of the client.

Question 2 of 5

The nurse has been teaching a woman who has iron deficiency anemia. Which menu, if selected, indicates that the woman understands her dietary instructions?

Correct Answer: C

Rationale: Broccoli, spinach, and orange juice (vitamin C enhances iron absorption) are iron-rich, ideal for anemia. Other menus lack sufficient iron sources.

Question 3 of 5

The nurse is teaching a group of parents about gross motor development of a 2-year old. According to the Denver Developmental Screening Test, which behavior is an example of the normal gross motor skill of a 2-year old?

Correct Answer: A

Rationale: Pulling a toy is a gross motor skill for a 2-year-old per the Denver Test. Copying a line and building a tower of eight blocks are fine motor skills. Broad jumping develops later.

Question 4 of 5

The nursing assistant is caring for an adult who has a fractured femur and is in Buck's extension traction awaiting surgery. The nurse is observing the nursing assistant administer morning care. Which action by the nursing assistant needs correction?

Correct Answer: D

Rationale: Turning the client on the side disrupts Buck's traction alignment, which requires constant pull. Weights should stay in place, head turning is safe, and bed-making direction is irrelevant.

Question 5 of 5

A pregnant client who is at 34 weeks gestation is diagnosed with a pulmonary embolism (PE). Which of these medications would the nurse anticipate the provider ordering?

Correct Answer: C

Rationale: Heparin infusion to maintain the PTT at 1.5-2.5 times the control value. In pregnant women with pulmonary embolism, heparin is preferred over warfarin due to warfarin's teratogenic effects. A continuous heparin infusion is typically used to achieve therapeutic anticoagulation, monitored by maintaining the PTT at 1.5-2.5 times the control value.

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