Nokea
A nurse is caring for a client who is postpartum. Which of the following documentations should the nurse include in the client's health record?
- A. Episiotomy approximated, 3 cm (1.18 in) in length.
- B. Client instructed on self-care needs.
- C. Client drank adequate amounts of fluid with meals.
- D. Oral temperature elevated at 0800.
Correct Answer: A
Rationale: Specific, measurable data like episiotomy status is critical for the health record.
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A nurse is preparing to administer ampicillin to a school-age child who weighs 55 lb. The provider prescribes 50 mg/kg/day in 4 equal doses. Available is ampicillin oral suspension 125 mg/5 mL. How many ml should the nurse administer with each dose?
- A. 12.5 mL (calculated: 55 lb = 25 kg, 50 mg/kg = 1250 mg/day, 1250 mg / 4 doses = 312.5 mg/dose, 312.5 mg / 125 mg/5 mL = 12.5 mL)
Correct Answer: A
Rationale: Calculation confirms 12.5 mL per dose is correct.
A nurse is assisting in the care of a client who just started receiving a blood transfusion 5 min ago. Which of the following findings should be reported first to the provider?
- A. Hyperthermia
- B. Urticaria
- C. Dyspnea
- D. Headache
Correct Answer: C
Rationale: Dyspnea is a critical sign of a transfusion reaction, requiring immediate reporting.
A nurse is reinforcing discharge teaching with a male client who has an indwelling urinary catheter. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will clamp the tube when I go for a walk.
- B. I will keep the drainage bag below the level of my waist.
- C. I will empty my drainage bag once a day.
- D. I will apply antiseptic ointment to the tip of my penis.
Correct Answer: B
Rationale: Keeping the bag below the waist prevents urine backflow and infection.
A nurse is assisting in the care of a client who is receiving newly prescribed IV antibiotics. Which of the following findings should the nurse report immediately?
- A. Small, raised vesicles over the body
- B. Rhinitis
- C. Itching of the skin
- D. Severe wheezing
Correct Answer: D
Rationale: Severe wheezing indicates a possible anaphylactic reaction, requiring immediate reporting.
A nurse is reinforcing teaching with a client about the use of a quad cane. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should move my stronger leg forward before moving my weaker leg.
- B. I will hold the cane on my stronger side.
- C. I will move the cane forward 18 inches.
- D. I should wear shoes with smooth soles to help slide my weak leg forward.
Correct Answer: B
Rationale: Holding the cane on the stronger side provides optimal support.