Nokea
For each potential assessment finding, click to specify if the assessment finding is consistent with mastitis or endometritis. Each finding may support more than 1 disease process.
- A. Foul-smelling lochia
- B. Painful, tender breast
- C. Temperature
- D. Chills
Correct Answer: B: Mastitis; A, C, D: Both
Rationale: The correct answer is B: Painful, tender breast - consistent with mastitis. Mastitis is an infection of the breast tissue, causing pain and tenderness. A: Foul-smelling lochia can be seen in both mastitis and endometritis. C: Temperature can be elevated in both conditions due to infection. D: Chills can also be present in both mastitis and endometritis as a response to infection. The other choices are left blank as they do not specifically align with either mastitis or endometritis in terms of assessment findings.
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A nurse is collecting a sputum specimen from a client who has tuberculosis. Which of the following actions should the nurse take?
- A. Wait 1 day to collect the specimen if the client cannot provide sputum.
- B. Wear sterile gloves to collect the specimen from the client.
- C. Ask the client to provide 15 to 20 mL of sputum into the container
- D. Obtain the specimen immediately upon the client waking up.
Correct Answer: D
Rationale: The correct answer is D: Obtain the specimen immediately upon the client waking up. This is the correct action because sputum is most concentrated in the morning, making it easier to collect a good sample for testing. Waiting 1 day (A) can delay treatment. Wearing sterile gloves (B) is important but not specific to sputum collection. Asking for 15-20mL of sputum (C) is appropriate, but the timing of collection is crucial.
A nurse is providing discharge teaching to a client following a total gastrectomy. The nurse should instruct the client about which of the following medications?
- A. Ranitidine
- B. Vitamin B12
- C. Vitamin K
- D. Metoclopramide
Correct Answer: B
Rationale: The correct answer is B: Vitamin B12. Following a total gastrectomy, the client will have reduced intrinsic factor production, leading to vitamin B12 deficiency. Supplementing with Vitamin B12 is crucial to prevent pernicious anemia. Ranitidine (A) is a gastric acid reducer and is not necessary after gastrectomy. Vitamin K (C) is primarily produced in the intestines and is not directly impacted by gastrectomy. Metoclopramide (D) is a prokinetic agent used for gastric motility and is not essential post-gastrectomy.
A nurse in a clinic is planning care for a child who has ADHD and is taking atomoxetine. Which of the following laboratory values should the nurse monitor?
- A. Liver function tests
- B. Kidney function tests
- C. Hemoglobin and hematocrit
- D. Serum sodium and potassium
Correct Answer: A
Rationale: The correct answer is A: Liver function tests. Atomoxetine is known to potentially cause liver injury. Monitoring liver function tests is crucial to detect any signs of liver damage early on. Kidney function tests (B), hemoglobin and hematocrit (C), and serum sodium and potassium (D) are not directly associated with atomoxetine use in ADHD. Monitoring liver function is the priority in this case.
A nurse in an emergency department is caring for a 3-year-old child who has suspected epiglottitis. Which of the following actions should the nurse take?
- A. Prepare to assist with intubation.
- B. Obtain a throat culture.
- C. Suction the child's oropharynx.
- D. Prepare a cool mist tent
Correct Answer: A
Rationale: The correct answer is A: Prepare to assist with intubation. Epiglottitis is a medical emergency where the swelling of the epiglottis can rapidly obstruct the airway, leading to respiratory distress or failure. Intubation is crucial to secure the airway and ensure adequate oxygenation. Obtaining a throat culture (B) may delay necessary intervention. Suctioning the oropharynx (C) can trigger spasm and worsen the obstruction. Cool mist tent (D) does not address the immediate need for securing the airway.
A nurse is caring for a client who has severe hypertension and is to receive nitroprusside via continuous IV infusion. Which of the following actions should the nurse plan to take?
- A. Monitor blood pressure every 2 hr.
- B. Attach an inline filter to the IV tubing
- C. Protect the IV bag from exposure to light.
- D. Keep calcium gluconate at the client's bedside.
Correct Answer: C
Rationale: The correct answer is C: Protect the IV bag from exposure to light. Nitroprusside is light-sensitive and can degrade when exposed to light, leading to the formation of toxic metabolites. By protecting the IV bag from light exposure, the nurse ensures the medication's stability and prevents potential harm to the client. Monitoring blood pressure every 2 hours (Choice A) is a standard practice for clients receiving nitroprusside but is not the most critical action. Attaching an inline filter to the IV tubing (Choice B) is important to prevent particulate matter from entering the client's bloodstream but is not specific to nitroprusside administration. Keeping calcium gluconate at the client's bedside (Choice D) is unrelated to nitroprusside administration and is not necessary for this situation.