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Questions 164

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Extract:


Question 1 of 5

While collecting data from pregnant clients in the obstetric clinic, the nurse should alert the health care provider to see which client first?

Correct Answer: C

Rationale: Decreased fetal movement in the second trimester suggests potential fetal distress, requiring urgent evaluation. Nausea, UTI symptoms, and third-trimester pain are concerning but less immediately critical.

Extract:

Exhibit 1
Vital signs

0800
Temperature 98.4 F (36.8 C)
Blood pressure 110/72 mm Hg
Heart rate 52/min
Respirations 16/min

Exhibit 2
Laboratory results

0800
Hematocrit
Male: 42%–52%
(0.42-0.52)
Female: 37%–47%
(0.37–0.47) 40%
(0.4)
Hemoglobin
Male: 14.0–18.0 g/dL
(140–180 g/L)
Female: 12.0–16.0 g/dL
(120–160 g/L) 14.0 g/dL
(140 g/L)
Platelets
150,000–400,000/mm3
(150–400 × 109/L) 200,000/mm3
(200 × 109/L)
Potassium
3.5-5.0 mEq/L
(3.5-5.0 mmol/L) 4.0 mEq/L
(4.0 mmol/L)


Exhibit 3
Medication administration record

Allergies: No known drug allergies

Medications Time
Aspirin: 81 mg by mouth, daily 0900
Docusate sodium: 100 mg by mouth, daily 0900
Lisinopril: 5 mg by mouth, daily 0900
Metoprolol: 100 mg by mouth, twice daily 0900, 1700
Simvastatin: 20 mg by mouth, daily 2000


Question 2 of 5

A client with ST segment elevation myocardial infarction is due for 0900 medications. Based on the data shown in the exhibit, which medications should the nurse administer? Select all that apply.

Correct Answer: A,C,D,E

Rationale: Aspirin (antiplatelet), lisinopril (ACE inhibitor), metoprolol (beta-blocker), and simvastatin (statin) are standard for STEMI to reduce clot formation, blood pressure, and cholesterol. Docusate is unrelated to STEMI management.

Extract:

Laboratory reference ranges
INR
0.8-1.1


Question 3 of 5

The nurse receives report on 4 clients. Which of the following clients should the nurse see first?

Correct Answer: A

Rationale: Discomfort at an IV vancomycin site suggests possible infiltration or phlebitis, requiring immediate assessment to prevent tissue damage. INR of 1.9 is subtherapeutic but less urgent, itching/nausea are expected morphine side effects, and tubing changed 48 hours ago is within standard protocol.

Extract:


Question 4 of 5

While caring for a child with Reye's syndrome, the nurse should give which action the highest priority?

Correct Answer: C

Rationale: Assess level of consciousness. An altered level of consciousness suggests increasing intracranial pressure related to cerebral edema.

Question 5 of 5

The nurse reinforces teaching for a client taking atorvastatin to call the health care provider if experiencing which symptom associated with a serious adverse effect of the medication?

Correct Answer: C

Rationale: Muscle aches may indicate myopathy or rhabdomyolysis, serious atorvastatin side effects requiring immediate attention. Diarrhea, headaches, and numbness are less specific or unrelated.

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