A nurse is assessing a client who has been taking oral contraceptives for the past 6 months. Which of the following findings should the nurse immediately report to the provider?
Persistent headache.
Weight gain 2.3 kg (5 lb).
Frequent nausea.
Breast tenderness.
The Correct Answer is A
Choice A reason: Persistent headache on oral contraceptives may indicate serious complications like stroke or hypertension, requiring immediate reporting to prevent life-threatening events. This is critical for timely intervention, ensuring client safety, and guiding potential medication adjustments in women using hormonal contraception for 6 months.
Choice B reason: Weight gain of 2.3 kg is common with oral contraceptives and not urgent, unlike persistent headache, which signals serious risks. Assuming weight gain requires reporting risks overlooking critical neurological symptoms, critical to avoid in ensuring safe monitoring of contraceptive side effects.
Choice C reason: Frequent nausea is a common contraceptive side effect, typically managed with counseling, not urgent like headache. Assuming nausea is priority risks delaying serious symptom evaluation, critical to prevent in ensuring timely reporting of potentially life-threatening complications in contraceptive users.
Choice D reason: Breast tenderness is a common, non-urgent side effect of oral contraceptives, unlike persistent headache, which may indicate stroke risk. Assuming tenderness is urgent risks missing critical symptoms, critical to avoid in ensuring proper monitoring and safety in clients on hormonal contraception.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: A 10-mL syringe produces high pressure, risking tissue damage during wound irrigation; low-pressure flow is safer. Assuming a 10-mL syringe is appropriate risks harming the wound, critical to avoid in ensuring gentle, effective irrigation for abdominal incision healing in wound care.
Choice B reason: Irrigating with low-pressure flow (e.g., 35-mL syringe or irrigation system) gently cleanses the abdominal incision, preventing tissue trauma while removing debris. This is critical for infection prevention, promoting healing, and ensuring safe wound care, essential for effective management of surgical incisions in clients.
Choice C reason: Cleansing from bottom to top risks dragging contaminants into the wound; top-to-bottom is standard. Assuming upward cleansing is correct risks infection, critical to prevent in ensuring proper wound hygiene and healing for clients with abdominal incisions during wound care.
Choice D reason: Cleansing drain sites involves circular motion from center outward, not inward, to avoid contamination. Low-pressure irrigation is key for wounds. Assuming inward motion is correct risks infection, critical to avoid in ensuring proper wound and drain care for abdominal incisions.
Correct Answer is A
Explanation
Choice A reason: Checking IV pump cords for fraying ensures electrical safety, preventing shocks or malfunctions, critical for client and staff safety. This routine inspection is essential for equipment reliability, supporting safe infusion delivery, and adhering to hospital safety protocols in managing IV therapy for clients.
Choice B reason: Removing the safety inspection sticker is inappropriate; it verifies equipment safety. Checking cords is correct. Assuming sticker removal is needed risks using unverified equipment, potentially causing malfunctions, critical to avoid in ensuring safe IV pump operation for client infusions.
Choice C reason: Grasping the cord to unplug risks damage or shock; the plug should be held. Checking cords is priority. Assuming cord grasping is safe risks electrical hazards, critical to prevent in ensuring safe handling and operation of IV pumps in client care settings.
Choice D reason: Two-prong outlets are outdated; medical equipment requires three-prong grounded outlets. Checking cords is key. Assuming two-prong outlets are safe risks electrical hazards, critical to avoid in ensuring proper IV pump function and safety for clients receiving infusions in healthcare settings.
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