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What physical assessment data should the nurse consider a normal finding for a primigravida client who is 12 hours postpartum?
- A. Soft, spongy fundus.
- B. Saturating two perineal pads per hour.
- C. Pulse rate of 56 BPM.
- D. Unilateral lower leg pain.
Correct Answer: C
Rationale: The correct answer is C: Pulse rate of 56 BPM. A normal finding for a primigravida client 12 hours postpartum would be a lower pulse rate as the body is recovering from childbirth. A pulse rate of 56 BPM is within the normal range for an adult.
A: Soft, spongy fundus would be a concerning finding as it could indicate uterine atony.
B: Saturating two perineal pads per hour would be excessive bleeding and could indicate postpartum hemorrhage.
D: Unilateral lower leg pain could be a sign of deep vein thrombosis, which is a potential complication postpartum.
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The client has acute pancreatitis. Which nursing intervention is the highest priority?
- A. Administer pain medication as prescribed.
- B. Monitor the client's serum amylase and lipase levels.
- C. Encourage oral intake of clear liquids.
- D. Assess the client's bowel sounds every 4 hours.
Correct Answer: A
Rationale: The correct answer is A: Administer pain medication as prescribed. This is the highest priority because acute pancreatitis is a painful condition, and managing pain is crucial for the client's comfort and well-being. Pain control also helps reduce stress on the pancreas and can aid in preventing complications.
Choice B is incorrect because while monitoring serum amylase and lipase levels is important in diagnosing pancreatitis and assessing response to treatment, it is not the highest priority intervention.
Choice C is incorrect as encouraging oral intake of clear liquids may exacerbate pancreatitis symptoms and lead to further complications.
Choice D is incorrect as assessing bowel sounds, while important for monitoring gastrointestinal function, is not the highest priority in the acute management of pancreatitis.
When assessing a client reporting severe pain in the right lower quadrant of the abdomen, which sign would most likely indicate appendicitis?
- A. Rebound tenderness at McBurney's point.
- B. Positive Murphy's sign.
- C. Rovsing's sign.
- D. Cullen's sign.
Correct Answer: A
Rationale: The correct answer is A: Rebound tenderness at McBurney's point. McBurney's point is located in the right lower quadrant and is a classic sign of appendicitis. Rebound tenderness at this point indicates inflammation in the peritoneum, suggesting appendicitis. Choices B, C, and D are not specific to appendicitis. Positive Murphy's sign is related to cholecystitis, Rovsing's sign is seen in acute appendicitis but is not as specific as rebound tenderness at McBurney's point, and Cullen's sign is associated with acute pancreatitis.
A client from a nursing home is admitted with urinary sepsis and has a single-lumen, peripherally-inserted central catheter (PICC). Four medications are prescribed for 9:00 a.m. and the nurse is running behind schedule. Which medication should the nurse administer first?
- A. Piperacillin/tazobactam (Zosyn) in 100 ml D5W, IV over 30 minutes q8 hours.
- B. Vancomycin (Vancocin) 1 gm in 250 ml D5W, IV over 90 minutes q12 hours.
- C. Pantoprazole (Protonix) 40 mg PO daily.
- D. Enoxaparin (Lovenox) 40 mg subq q24 hours.
Correct Answer: A
Rationale: The correct answer is A: Piperacillin/tazobactam (Zosyn) in 100 ml D5W, IV over 30 minutes q8 hours. In a patient with urinary sepsis, timely administration of antibiotics is crucial to prevent further complications. Piperacillin/tazobactam is a broad-spectrum antibiotic effective against a wide range of bacteria commonly involved in sepsis. Administering it first ensures prompt initiation of treatment. Other choices (B) Vancomycin, (C) Pantoprazole, and (D) Enoxaparin are important medications but are not as time-sensitive in this scenario. Vancomycin and Enoxaparin have longer administration times, and Pantoprazole is a maintenance medication that is not urgent in the acute management of sepsis.
The client has just been diagnosed with Addison's disease. Which clinical manifestation should the nurse expect to find?
- A. Hypertension and hyperglycemia.
- B. Hyperpigmentation and hypotension.
- C. Exophthalmos and tachycardia.
- D. Weight gain and fluid retention.
Correct Answer: B
Rationale: The correct answer is B: Hyperpigmentation and hypotension. Addison's disease is characterized by adrenal insufficiency, leading to low cortisol and aldosterone levels. Hyperpigmentation occurs due to elevated levels of ACTH, causing melanin deposition. Hypotension results from aldosterone deficiency, leading to sodium and water loss. Choice A is incorrect because Addison's disease does not typically present with hypertension or hyperglycemia. Choice C is incorrect as exophthalmos and tachycardia are not typically associated with Addison's disease. Choice D is incorrect as weight gain and fluid retention are not common manifestations of Addison's disease.
A male infant born at 30-weeks gestation at an outlying hospital is being prepared for transport to a Level IV neonatal facility. His respirations are 90/min, and his heart rate is 150 beats per minute. Which drug is the transport team most likely to administer to this infant?
- A. Ampicillin (Omnipen) 25 mg/kg slow IV push.
- B. Gentamicin sulfate (Garamycin) 2.5 mg/kg IV.
- C. Digoxin (Lanoxin) 20 micrograms/kg IV.
- D. Beractant (Survanta) 100 mg/kg per endotracheal tube.
Correct Answer: D
Rationale: The correct answer is D: Beractant (Survanta) 100 mg/kg per endotracheal tube. In this scenario, the infant's high respiratory rate indicates respiratory distress, likely due to immature lungs. Beractant is a pulmonary surfactant used to treat respiratory distress syndrome in preterm infants by improving lung function and reducing the risk of complications. Administering beractant via endotracheal tube helps deliver the medication directly to the lungs.
Choice A (Ampicillin) is an antibiotic used for treating infections, not respiratory distress. Choice B (Gentamicin) is an antibiotic for infections, not respiratory distress. Choice C (Digoxin) is a cardiac medication for heart conditions, not respiratory distress. Therefore, only choice D addresses the respiratory distress issue in the preterm infant, making it the most appropriate drug for the transport team to administer in this case.