Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who is experiencing a postpartum hemorrhage and has a prescription for methylergonovine. Which of the following findings should the nurse identify as a contraindication to the administration of this medication?
A. WBC count 12.000/mm3
A slightly elevated WBC count is not a contraindication for the administration of methylergonovine.
B. History of asthma
Methylergonovine can cause vasoconstriction and bronchoconstriction, which can exacerbate asthma symptoms. Therefore, a history of asthma is a contraindication for its use.
C. Hgb 11.2 g/dL.
Hgb of 11.2 g/dL is within an acceptable range and not a contraindication for methylergonovine.
D. Blood pressure 154/98 mm Hg
Blood pressure of 154/98 mm Hg is elevated, but it is not a contraindication for the administration of methylergonovine.
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Full Explanation
Choice A rationale:
A slightly elevated WBC count is not a contraindication for the administration of methylergonovine.
Choice B rationale:
Methylergonovine can cause vasoconstriction and bronchoconstriction, which can exacerbate asthma symptoms. Therefore, a history of asthma is a contraindication for its use.
Choice C rationale:
Hgb of 11.2 g/dL is within an acceptable range and not a contraindication for methylergonovine.
Choice D rationale:
Blood pressure of 154/98 mm Hg is elevated, but it is not a contraindication for the administration of methylergonovine.
Similar Questions
A nurse is providing discharge teaching to the parents of a 9-month-old male infant who is postoperative following a hypospadias repair. Which of the following statements should the nurse make?
A. "Expect your baby to have the urinary catheter for about 1 week."
Following hypospadias repair, a urinary catheter is often placed to ensure proper healing. The duration of catheterization varies, but about 1 week is a common timeframe.
B. "You should clamp the catheter tubing for 10 minutes three times per day."
Clamping the catheter tubing for extended periods is not a standard practice and can cause discomfort and complications.
C. "Apply an antifungal ointment to your baby's penis twice daily."
Applying antifungal ointment is not typically required after hypospadias repair.
D. "Your baby will take a prophylactic antibiotic for the next 6 weeks.
A prophylactic antibiotic is not typically prescribed for 6 weeks following hypospadias repair.
Full Explanation
Choice A rationale:
Following hypospadias repair, a urinary catheter is often placed to ensure proper healing. The duration of catheterization varies, but about 1 week is a common timeframe.
Choice B rationale:
Clamping the catheter tubing for extended periods is not a standard practice and can cause discomfort and complications.
Choice C rationale:
Applying antifungal ointment is not typically required after hypospadias repair.
Choice D rationale:
A prophylactic antibiotic is not typically prescribed for 6 weeks following hypospadias repair.
A nurse is reviewing the medical record of an older adult client who is confused to place and time. Which of the following actions should the nurse plan to take?
A. Place the client on a low-protein diet
Placing the client on a low-protein diet is not appropriate based solely on the provided information.
B. Restrict the client's intake of dietary sodium.
Restricting dietary sodium might be considered for specific conditions but is not directly related to the client's confusion.
C. Ask the provider to decrease the magnesium hydroxide dosage.
A high magnesium level can contribute to confusion in older adults. Requesting a reduction in the magnesium hydroxide dosage can help address this issue.
D. Request a prescription to discontinue diphenhydramine.
Discontinuing diphenhydramine might be considered if it is contributing to the client's confusion, but there is no specific information provided to support this action.
Full Explanation
Choice A rationale:
Placing the client on a low-protein diet is not appropriate based solely on the provided information.
Choice B rationale:
Restricting dietary sodium might be considered for specific conditions but is not directly related to the client's confusion.
Choice C rationale:
A high magnesium level can contribute to confusion in older adults. Requesting a reduction in the magnesium hydroxide dosage can help address this issue.
Choice D rationale:
Discontinuing diphenhydramine might be considered if it is contributing to the client's confusion, but there is no specific information provided to support this action.
A nurse is developing a plan of care for a client who has schizophrenia and is experiencing auditory hallucinations. Which of the following actions should the nurse plan to take? (Select all that apply.)
A. Ask the client to explain what she is hearing.
Asking the client to explain what she is hearing may not be helpful, as the client's perception of the hallucinations may not match reality.
B. Convey empathy toward the client.
Conveying empathy is important to establish a therapeutic relationship and provide emotional support.
C. Encourage the client to listen to music through headphones.
Encouraging the client to listen to music through headphones can help distract from auditory hallucinations.
D. Speak simply when communicating with the client.
Speaking simply and clearly when communicating helps the client understand and process information more effectively.
E. Use therapeutic touch when caring for the client.
Using therapeutic touch might not be appropriate for all clients and should be based on the client's preferences and comfort level.
Full Explanation
Choice A rationale:
Asking the client to explain what she is hearing may not be helpful, as the client's perception of the hallucinations may not match reality.
Choice B rationale:
Conveying empathy is important to establish a therapeutic relationship and provide emotional support.
Choice C rationale:
Encouraging the client to listen to music through headphones can help distract from auditory hallucinations.
Choice D rationale:
Speaking simply and clearly when communicating helps the client understand and process information more effectively.
Choice E rationale:
Using therapeutic touch might not be appropriate for all clients and should be based on the client's preferences and comfort level.