Nokea
A client asks the nurse about including her 2 and 12 year-old sons in the care of their newborn sister. Which of the following is an appropriate initial statement by the nurse?
- A. Focus on your sons' needs during the first days at home.
- B. Tell each child what he can do to help with the baby.
- C. Suggest that your husband spend more time with the boys.
- D. Ask the children what they would like to do for the newborn.
Correct Answer: A
Rationale: In an expanded family, it is important for parents to reassure older children that they are loved and as important as the newborn.
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A client is admitted to the coronary care unit with an acute myocardial infarction. The pain associated with acute myocardial infarction results from:
- A. Spasm of the coronary artery
- B. Ischemia of the myocardium
- C. Vasodilation of the coronary veins
- D. Ischemia of the carotid artery
Correct Answer: B
Rationale: Myocardial infarction pain is caused by ischemia of the myocardium due to reduced blood flow, leading to tissue hypoxia.
The nurse is reviewing the chart of a client who gave birth 4 hours ago. Which factor increases the client's risk for postpartum hemorrhage?
- A. Labor and birth without pain medication
- B. Labor length of 8 hours
- C. Newborn weight of 9 lb 2 oz (4140 g)
- D. Third stage of labor lasting 20 minutes
Correct Answer: C
Rationale: A large newborn (macrosomia, >4000 g) increases the risk of uterine atony, a major cause of postpartum hemorrhage. Labor without pain medication, an 8-hour labor, and a 20-minute third stage are not significant risk factors.
All of the following clients need attention. Which one should the nurse go to first?
- A. The nursing assistant reports that a client who had a T3 spinal cord transection several months ago has a severe headache and blurred vision.
- B. The nursing assistant needs help turning a client who had a CVA.
- C. The physician is about to examine a client who has multiple sclerosis and requests that the nurse be present.
- D. A client who has amyotrophic lateral sclerosis needs help with ambulating.
Correct Answer: A
Rationale: Severe headache and blurred vision in spinal cord injury suggest autonomic dysreflexia, a life-threatening emergency, prioritizing immediate attention over turning, examination, or ambulation.
A client with cancer pain is prescribed oxycodone. Which information is most essential to reinforce in order to help prevent long-term complications?
- A. How to monitor blood pressure daily
- B. How to prevent constipation
- C. How to prevent itching
- D. How to prevent nausea
Correct Answer: B
Rationale: Constipation is a common, long-term complication of oxycodone, requiring preventive measures like fiber and fluids. Blood pressure monitoring, itching, and nausea are less critical long-term concerns.
What should the nurse do when ambulating a client who has a portable wound drainage system?
- A. Remove the drainage catheter during ambulation
- B. Fasten the collection device below the wound
- C. Completely empty the collection device before ambulating
- D. Disconnect the suction apparatus from the client before ambulating
Correct Answer: B
Rationale: Fastening the drainage device below the wound promotes gravity-dependent drainage, preventing reflux and infection during ambulation.