142) ANSWER

C) Angiotensin-converting enzyme (ACE) inhibitors

RATIONALE

Because ACE inhibitors can cause fetal harm or death, they should be discontinued as soon as pregnancy is detected. The effect on breastfeeding infants is unknown. The effect of other medications is unknown during pregnancy. There is only one correct answer to this question. In order to select the correct answer, review the complications of each medication.

141) ANSWER

B) Venous drainage from the brain.

RATIONALE

Keeping the head of the bed elevated to 30 degrees promotes venous drainage, which is important in decreasing ICP. Alignment of the head prevents obstruction of the jugular veins. Obstruction would impede venous drainage. Recall that appropriate drainage is enhanced by gravity. Keeping the head of the bed elevated will promote drainage.

140) ANSWER

A) Whiteheads

RATIONALE

Whiteheads are classified as closed comedones. Blackheads are open comedones. Options 3 and 4 are irrelevant. The core issue of the question is knowledge of various skin eruptions. The wording of the question tells you that the correct response is also a true statement of fact. Use the process of elimination and nursing knowledge to make a selection.

139) ANSWER

C) Eupnea respirations

RATIONALE

The action of theophylline is bronchodilation, which should relax respiratory efforts. Eupnea is normal respirations, which should be a direct result of bronchodilation. Recall that eupnea means normal breathing, which is the goal of therapy.

138) ANSWER

A) Hamburger with enriched bun

RATIONALE

Anemia in pregnancy is often caused by inadequate iron intake. Lean meat and enriched bread are good sources of iron. Knowledge of foods high in iron will help to answer the question correctly. Take time to review these if needed.

137) ANSWER

A) Space interventions and encourage rest periods.

RATIONALE

Activity intolerance in clients with anemia results from the imbalance between oxygen demand and supply. Activities should be planned to intersperse activity with periods of rest to decrease hypoxemic episodes and to decrease tissue demand for oxygen. All the other options are appropriate interventions for a client with anemia, but they do not relate to the nursing diagnosis of activity intolerance. The core issue of the question is knowledge that anemia causes fatigue and that measures to prevent fatigue need to be incorporated in the plan of care. Use this knowledge and the process of elimination to make a selection.

136) Answer

A. Reduces the risk of DVTs

Rationale

•DVTs are prevented with the use of anticoagulation, compression stockings, sequential compression devices, and exercise. Having the head of bed at 15 to 30 degrees will not signigicantly affect the risk of DVTs.

•A patient with an increased intracranial pressure should have their bed elevated to 15-30 degrees. This will help increase venous outflow, which decreases ICP. Elevating the head too much can decrease cerebral perfusion pressure, causes hypoxia and ischemia.