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Questions 158

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Question 1 of 5

Which of the following nursing orders should be included in the plan of care for a client with hepatitis C?

Correct Answer: A

Rationale: Universal precautions are critical due to the bloodborne nature of hepatitis C. The other options are not appropriate for hepatitis C care.

Question 2 of 5

A primigravida with diabetes is admitted to the labor and delivery unit at 34 weeks gestation. Which physician's order should the nurse question?

Correct Answer: B

Rationale: Terbutaline (Brethine) a tocolytic is used to stop preterm labor but is contraindicated in diabetic patients due to its risk of causing hyperglycemia. The other medications are appropriate for preeclampsia (magnesium sulfate) pain (butorphanol) or infection prophylaxis (cefazolin).

Question 3 of 5

The nurse is caring for a client with a history of systemic lupus erythematosus. The nurse should expect the client to have:

Correct Answer: A

Rationale: Systemic lupus erythematosus causes autoimmune inflammation, commonly leading to joint pain and arthritis-like symptoms.

Question 4 of 5

The nurse discovers that a 78-year-old client who received hydralazine (Apresoline) 20 mg 45 minutes ago has a blood pressure of 70/40 mm Hg. The client has been on this dose of the medication for 3 years. Which of the following data is most likely significant in relation to the cause of the low blood pressure?

Correct Answer: B

Rationale: (A,
D) Decreased pulse volume and increased pulse rate are signs of an acute hypotensive episode. Inadequate fluid volume when taking vasodilators can result in a drop in blood pressure when vasodilation starts to physiologically occur as an action of the drug. A potassium level of 3.3 would not be associated with a significant drop in blood pressure.

Question 5 of 5

A seventh grader lost consciousness after being hit in the head with a basketball. In the emergency room his vital signs are stable, and he demonstrates no neurologic deficit. He will not be admitted to the hospital. It is most important that you advise his mother to:

Correct Answer: D

Rationale: If the child cannot be awakened from sleep after head injury, it is an indication of serious increase in ICP. The mother should call an ambulance right away.

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