1.A nurse is assessing a client who has gestational diabetes mellitus and is experiencing hyperglycemia.

Which of the following findings should the nurse expect?

a. Reports increased urinary output

i. MY ANSWER: Increased urinary output, nausea and vomiting, reports of thirst,

abdominal pain, constipation, drowsiness, and headaches are manifestations of

hyperglycemia. Other manifestations include weak rapid pulse, fruity breath odor, urine

positive for sugar and acetone, and a blood glucose level greater than 200 mg/dL.

b. Diaphoresis. Diaphoresis or clammy skin is a finding of hypoglycemia. Flushed, dry skin is a

manifestation of hyperglycemia.

c. Reports blurred vision. Blurred or double vision is a finding of hypoglycemia. A report of dim

vision is a manifestation of hyperglycemia.

d. Shallow respirations. Shallow respirations are a finding of hypoglycemia. Rapid breathing is a

manifestation of hyperglycemia.

2. A nurse is caring for a client who is at 22 weeks of gestation and is HIV positive. Which of the

following actions should the nurse take?

a. Administer penicillin G 2.4 million units IM to the client. The nurse should

 administer penicillin G 2.4 million units IM to a client who has syphilis.

b. Instruct the client to schedule an annual pelvic examination. The nurse should instruct the client

to schedule a pelvic examination every 6 months.

c. Tell the client she will start medication for HIV immediately after delivery.

 The nurse should tell the client that treatment for HIV will be during the prenatal and

perinatal periods. Treatment with antiretroviral prophylaxis such as zidovudine, triple-drug

antiretroviral therapy (ART), or highly active antiretroviral therapy (HAART) during pregnancy

have been reported to decrease the transmission of the virus to the newborn.

d. Report the client's condition to the local health department.

i. MY ANSWER. The nurse should report the condition to the local health department. HIV

is one of the conditions on the list of Nationally Notifiable Infectious Conditions that is

required to be reported.

3. A nurse is providing teaching for a client who has a new prescription for combined oral contraceptives.

Which of the following findings should the nurse include as an adverse effect of the medication?

a. Depression.

i. MY ANSWER. The nurse should instruct the client that depression is a common adverse

effect of combined oral contraceptives. Other common adverse effects of the medication

include amenorrhea, weight gain, headache, nausea, breakthrough bleeding, and breast

tenderness.

b. Polyuria. Fluid retention can occur due to an excess of estrogen. Polyuria is not a common

adverse effect of the medication.

c. Hypotension. Hypertension, rather than hypotension, is a common adverse effect of combined

oral contraceptives.

d. Urticaria. Urticaria is not a common adverse effect of combined oral contraceptives.