Nokea
A client is to be discharged 48 hours after a normal vaginal delivery of an infant with no laceration or episiotomy. Which of the following danger signs should the client be advised to report to her physician? Select all that apply.
- A. Temperature higher than 38°C/100.4°F
- B. Difficulty urinating
- C. Swelling, redness, or pain in one or both legs
- D. Fatigue
- E. Foul-smelling vaginal discharge
Correct Answer: A,B,C,E
Rationale: Postpartum danger signs include fever >38°C (A), difficulty urinating (B), leg swelling/redness/pain (C, indicating possible DVT), and foul-smelling discharge (E, suggesting infection). Fatigue (D) is common and not necessarily a danger sign.
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The physician has ordered an infusion of Osmitrol (mannitol) for a client with increased intracranial pressure. Which finding indicates the direct effectiveness of the drug?
- A. Increased pulse rate
- B. Increased urinary output
- C. Decreased diastolic blood pressure
- D. Increased pupil size
Correct Answer: B
Rationale: Mannitol is an osmotic diuretic that reduces intracranial pressure by increasing urinary output, drawing fluid out of the brain tissue.
A client with deep vein thrombosis is receiving a continuous heparin infusion and Coumadin PO. INR lab test result is 8.0. Which intervention would be most important to include in the nursing care plan?
- A. Assess for signs of abnormal bleeding
- B. Anticipate an increase in the heparin drip rate
- C. Instruct the client regarding the drug therapy
- D. Increase the frequency of vascular assessments
Correct Answer: A
Rationale: An INR of 8.0 is dangerously high, indicating a risk of bleeding. Assessing for abnormal bleeding is the priority to detect and manage potential complications.
The nurse working the organ transplant unit is caring for a client with a white blood cell count of 450. During evening visitation, a visitor brings a basket of fruit. What action should the nurse take?
- A. Allow the client to keep the fruit
- B. Place the fruit next to the bed for easy access by the client
- C. Offer to wash the fruit for the client
- D. Ask the family members to take the fruit home
Correct Answer: D
Rationale: A white blood cell count of 450 indicates severe immunosuppression, so the fruit should be removed to prevent infection from potential contaminants.
A client with chronic obstructive pulmonary disease (COPD) is admitted to the respiratory unit. Which physician prescription should the nurse question?
- A. Oâ‚‚ at 5 L/min by nasal cannula
- B. Solu Medrol 125 mg IV push every 6 hours
- C. Ceftriaxone (Rocephin) 1gram IVPB daily
- D. Darvocet N 100 po prn pain
Correct Answer: A
Rationale: High-flow oxygen (5 L/min) can suppress the hypoxic drive in COPD clients, risking CO2 retention. Low-flow oxygen (1-2 L/min) is safer and should be questioned.
The nurse is caring for a client who is postoperative day 1 following a laparoscopic appendectomy. The client reports shoulder pain. Which of the following actions should the nurse take?
- A. Administer an analgesic as ordered.
- B. Notify the physician immediately.
- C. Explain that this is referred pain from residual gas.
- D. Place the client in a prone position.
Correct Answer: C
Rationale: shoulder pain after laparoscopic surgery is often due to referred pain from residual carbon dioxide used during the procedure