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A nurse is assessing a client who is 4 hours postpartum. Which of the following findings should the nurse report to the provider?
- A. Lochia that is red and contains small clots.
- B. Fundus firm at the umbilicus.
- C. Fundus deviated to the right.
- D. Moderate perineal pain with swelling.
Correct Answer: C
Rationale: The correct answer is C. A fundus that is deviated to the right may indicate a full bladder, which should be addressed postpartum. Choice A is incorrect because red lochia with small clots is expected during the early postpartum period. Choice B is incorrect as the fundus should be firm and midline, not at the umbilicus. Choice D is incorrect as perineal pain and swelling are common postpartum findings that do not require immediate reporting to the provider.
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A client is being discharged with a new prescription for metoprolol. Which of the following instructions should the nurse include?
- A. Do not discontinue this medication suddenly.
- B. Take this medication in the evening to decrease the risk of falls.
- C. Monitor your heart rate before taking this medication.
- D. Avoid grapefruit juice while taking this medication.
Correct Answer: C
Rationale: The correct instruction for a client prescribed metoprolol is to monitor their heart rate before taking the medication. Metoprolol is a beta-blocker that can cause bradycardia (slow heart rate), so it is essential for clients to check their heart rate before each dose. Choice A is incorrect because abruptly stopping metoprolol can lead to adverse effects, so it should not be discontinued suddenly. Choice B is incorrect because there is no specific recommendation to take metoprolol at night to reduce falls. Choice D is incorrect because grapefruit juice can interact with metoprolol, affecting its absorption, and should be avoided.
A nurse in a provider's office is reviewing the laboratory results of a group of clients. Which of the following sexually transmitted infections is a nationally notifiable infectious disease that should be reported to the state health department?
- A. Chlamydia
- B. Human papillomavirus
- C. Candidiasis
- D. Herpes simplex virus
Correct Answer: A
Rationale: Chlamydia is the correct answer. Chlamydia is a sexually transmitted infection that is considered a nationally notifiable infectious disease, meaning healthcare providers are required to report cases to public health authorities. Reporting such cases is crucial for disease surveillance and implementing appropriate control measures. Human papillomavirus, Candidiasis, and Herpes simplex virus are not nationally notifiable infectious diseases and do not require mandatory reporting to the state health department.
A nurse is assessing a client who is 30 minutes postoperative following an arterial thrombectomy. What should the nurse report?
- A. Chest pain.
- B. Muscle spasms.
- C. Cool, moist skin.
- D. Incisional pain.
Correct Answer: A
Rationale: In this scenario, postoperative chest pain is a critical finding that must be reported promptly. Chest pain after an arterial thrombectomy could indicate serious complications such as myocardial infarction or pulmonary embolism. Muscle spasms and cool, moist skin are not the priority assessments in this situation. Incisional pain is common after surgery and is not typically a cause for immediate concern unless it is severe and accompanied by other symptoms.
A nurse is performing a gastric lavage for a client who has upper gastrointestinal bleeding. Which of the following actions should the nurse take?
- A. Instill 500 ml of solution through the NG tube
- B. Insert a large-bore NG tube
- C. Use a cold irrigation solution
- D. Instruct the client to lie on his right side
Correct Answer: B
Rationale: The correct answer is B: 'Insert a large-bore NG tube.' When performing a gastric lavage for a client with upper gastrointestinal bleeding, a large-bore NG tube is used to effectively remove gastric contents and blood. Option A is incorrect because the amount of solution to instill depends on the specific situation and should be guided by the healthcare provider's order. Option C is incorrect because using a cold irrigation solution can lead to hypothermia and is not recommended. Option D is incorrect as there is no need to instruct the client to lie on his right side specifically for gastric lavage.
A nurse is teaching a newly licensed nurse about therapeutic techniques to use when leading a group on a mental health unit. Which of the following group facilitation techniques should the nurse include in the teaching?
- A. Share personal opinions to help influence the group's values.
- B. Measure the accomplishments of the group against a previous group.
- C. Yield in situations of conflicts to maintain group harmony.
- D. Use modeling to help the clients improve their interpersonal skills.
Correct Answer: D
Rationale: The correct answer is D: 'Use modeling to help the clients improve their interpersonal skills.' Modeling is an effective therapeutic technique where the leader demonstrates appropriate behaviors for the group to learn from. This technique can help clients improve their interpersonal skills by observing and replicating positive behaviors. Choices A, B, and C are incorrect. Sharing personal opinions to influence the group's values may not be appropriate as it could hinder the group dynamics and individual autonomy. Comparing accomplishments against a previous group is not a recommended technique as each group is unique, and comparisons may not be beneficial. Yielding in conflicts to maintain group harmony may lead to unresolved issues and hinder the group's progress.