Nokea
A client is admitted to the postpartum floor after a vaginal birth. Which finding indicates the need for immediate intervention?
- A. Lochia that soaks a perineal pad every 2 hours
- B. Persistent headache with blurred vision
- C. Red, painful nipple on one breast
- D. Strong-smelling vaginal discharge
Correct Answer: B
Rationale: Headache with blurred vision (B) suggests preeclampsia, a life-threatening condition requiring immediate intervention. Lochia (A), nipple pain (C), and discharge (D) are normal or less urgent postpartum findings.
You may also like to solve these questions
A client with active pulmonary tuberculosis is prescribed 4-drug therapy with ethambutol. The nurse reinforces previous teaching to notify the health care provider immediately if which adverse effect associated with ethambutol occurs?
- A. Blurred vision
- B. Dark-colored urine
- C. Difficulty hearing
- D. Yellow skin
Correct Answer: A
Rationale: Ethambutol can cause optic neuritis, leading to blurred vision (A), a serious side effect requiring immediate reporting. Dark urine (B), hearing loss (C), and jaundice (D) are associated with other TB drugs (e.g., rifampin, isoniazid).
The nurse is planning care for a client who must remain in bed for several weeks. Which action will do most to prevent the development of pressure ulcers?
- A. Performing range-of-motion exercises
- B. Deep breathing and coughing
- C. Keeping the feet against a footboard
- D. Changing position in bed frequently
Correct Answer: D
Rationale: Frequent position changes relieve pressure on bony prominences, preventing pressure ulcers. ROM, breathing, or footboards address other complications.
A client with gout who was started on allopurinol a week ago calls the health care provider’s office with several concerns. The nurse should recognize which report by the client as being significant and requiring immediate follow-up?
- A. Also takes ibuprofen for pain
- B. Frequency of urination has increased
- C. Mild red rash has developed over torso
- D. Nausea occurs after each dose
Correct Answer: C
Rationale: A rash (C) may indicate a hypersensitivity reaction to allopurinol, potentially progressing to severe conditions like Stevens-Johnson syndrome, requiring immediate follow-up. Ibuprofen (A), urination (B), and nausea (D) are less urgent.
An adult is admitted with meningitis. During the acute phase of the illness, which measure should the nurse include in the nursing care plan to reduce the chance of seizures?
- A. Play the client's favorite music.
- B. Stimulate the client every two hours.
- C. Keep a padded tongue blade at the bedside.
- D. Darken the client's room.
Correct Answer: D
Rationale: Darkening the room minimizes sensory stimulation, reducing seizure risk in meningitis, where neurological irritability is common.
The nurse is floated from the obstetrical (OB) floor to the medical/surgical floor. Which client is the best assignment for the OB nurse?
- A. Female client with a fractured pelvis who is 4 months pregnant
- B. Female client with cytomegalovirus pneumonia
- C. Male client with an open bowel resection with a Foley catheter
- D. Male client with history of Billroth II surgery who is septic
Correct Answer: A
Rationale: The OB nurse’s expertise in pregnancy care makes the pregnant client with a fractured pelvis (A) the best assignment, as it aligns with their skills in managing maternal-fetal health. Other clients (B, C, D) require general medical-surgical care unrelated to OB.