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Questions 158

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Question 1 of 5

Which food selection would provide the most calcium for a client who is four months pregnant?

Correct Answer: C

Rationale: Yogurt is a rich source of calcium essential for fetal bone development during pregnancy. One cup provides approximately 300-400 mg of calcium significantly more than oatmeal bran muffins or oranges.

Question 2 of 5

A primigravida is at term. The nurse can recognize the second stage of labor by the client's desire to:

Correct Answer: A

Rationale: The second stage of labor is marked by full cervical dilation and the urge to push with contractions.

Question 3 of 5

A client has been taking lithium 300 mg po bid for the past two weeks. This morning her lithium level was 1 mEq/L. The nurse should:

Correct Answer: C

Rationale: There is no need to phone the physician because the lithium level is within therapeutic range and because there are no indications of toxicity present. There is no reason to withhold the lithium because the blood level is within therapeutic range. Also, it is necessary to give the medication as scheduled to maintain adequate blood levels. The lab results indicate that the client's lithium level is within therapeutic range (0.2-1.4 mEq/L), so the medication should be given as ordered. Benztropine is an antiparkinsonism drug frequently given to counteract extrapyramidal symptoms associated with the administration of antipsychotic drugs (not lithium).

Question 4 of 5

A female client who has chronic obstructive pulmonary disease (COPD) has presented in the emergency department with cough productive of yellow sputum and increasing shortness of breath. On room air, her blood gases are as follows: pH 7.30 mm Hg, PCO2 60 mm Hg, PO2 55 mm Hg, HCO3 32 mEq/L. These arterial blood gases reflect:

Correct Answer: D

Rationale: Low pH, high PCO2, and normal HCO3 indicate uncompensated respiratory acidosis, reflecting acute exacerbation of COPD.

Question 5 of 5

A client with a history of a kidney transplant is being discharged. The nurse should teach the client to:

Correct Answer: A

Rationale: Contact sports risk trauma to the transplanted kidney, located in the pelvis, and should be avoided. High-protein diets, fluid limits, and daily antibiotics are not standard.

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