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A nurse is caring for a patient who is postoperative following a cesarean section. Which of the following findings should the nurse report to the provider? Which finding post-cesarean should the nurse report?
- A. Lochia serosa
- B. Fundus firm at the umbilicus
- C. Mild cramping
- D. Foul-smelling vaginal discharge
Correct Answer: D
Rationale: The correct answer is D: Foul-smelling vaginal discharge. This finding indicates a possible infection, which is crucial to report to the provider for prompt intervention. Foul odor may indicate endometritis or other postoperative complications.
A: Lochia serosa is a normal finding post-cesarean.
B: Fundus firm at the umbilicus is a normal finding post-cesarean, indicating proper involution.
C: Mild cramping is common post-cesarean due to uterine contractions as it returns to its pre-pregnancy size.
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A patient with a history of migraines is at the clinic complaining of a throbbing headache. Which of the following questions should the nurse include in the assessment? Which question should the nurse ask for migraine assessment?
- A. Have you experienced any nausea or vomiting with your headache?
- B. Are the lights in this room bothering you?
- C. Have you noticed any confusion or clouded thinking?
- D. Did you feel weak before the headache started or do you feel weak now?
Correct Answer: A
Rationale: The correct answer is A: "Have you experienced any nausea or vomiting with your headache?" This question is crucial in assessing migraines as nausea and vomiting are common accompanying symptoms. Nausea and vomiting are associated with activation of the autonomic nervous system during migraines. The other options are not as directly related to migraines. B is more relevant to light sensitivity in migraines, C is more related to confusion or cognitive symptoms, and D is more focused on weakness, which are not typically primary symptoms of migraines.
A nurse is preparing to administer fluoxetine 40 mg PO daily. The available medication is fluoxetine 20 mg/mL. How many mL should the nurse administer? How many mL of fluoxetine should the nurse administer?
- A. 1
- B. 2
- C. 3
- D. 4
Correct Answer: B
Rationale: To calculate the mL of fluoxetine to administer, use the formula: desired dose (40 mg) / stock dose (20 mg/mL) = mL to administer. Therefore, 40 mg / 20 mg/mL = 2 mL. This is why choice B (2 mL) is correct. Choice A (1 mL) is incorrect as it does not provide the full dose. Choices C (3 mL) and D (4 mL) are incorrect as they exceed the required dose.
A nurse in a coronary care unit is admitting a patient who has had CPR following a cardiac arrest. The patient is receiving lidocaine IV at 2 mg/min. When the patient asks the nurse why he is receiving that medication, the nurse should explain that it has which of the following actions? Why is the patient receiving lidocaine?
- A. Relieves pain.
- B. Slows intestinal motility.
- C. Dissolves blood clots.
- D. Prevents dysrhythmias.
Correct Answer: D
Rationale: The patient is receiving lidocaine to prevent dysrhythmias after experiencing a cardiac arrest. Lidocaine is a class IB antiarrhythmic drug that stabilizes the cardiac cell membrane, reducing the likelihood of abnormal electrical activity and dysrhythmias. It does not relieve pain, slow intestinal motility, or dissolve blood clots. Therefore, the correct answer is D, as it directly addresses the purpose of administering lidocaine in this specific clinical scenario.
A nurse is caring for a patient who is receiving IV fluids. The nurse notes that the IV site is red, warm, and painful. Which of the following actions should the nurse take first? What should the nurse do first for IV site issues?
- A. Slow the infusion rate.
- B. Apply a warm compress.
- C. Discontinue the IV line.
- D. Notify the provider.
Correct Answer: C
Rationale: The correct action for the nurse to take first is to discontinue the IV line (choice C). This is essential to prevent further complications such as infection or infiltration. Discontinuing the IV line will stop the source of the redness, warmth, and pain at the IV site. Slowing the infusion rate (choice A) would not address the underlying issue and could potentially worsen the situation. Applying a warm compress (choice B) could also exacerbate the symptoms if there is an infection. Notifying the provider (choice D) is important but should come after the immediate action of discontinuing the IV line to address the IV site issues promptly.
A nurse is caring for a patient whose right leg is in Buck's traction. Which interventions should the nurse implement to promote the patient's mobility? Which intervention promotes mobility in Buck's traction?
- A. Perform passive range of motion exercises on the right leg.
- B. Perform isometric exercises on both legs.
- C. Perform active range-of-motion exercises on the left leg.
- D. Log roll the patient every 2 hours.
Correct Answer: C
Rationale: Rationale: Performing active range-of-motion exercises on the left leg promotes mobility in Buck's traction by maintaining muscle strength and joint flexibility, preventing muscle atrophy, and improving circulation. This helps prevent complications and supports eventual rehabilitation. Passive range of motion exercises on the right leg are not recommended as it may cause discomfort. Isometric exercises on both legs may not address the specific immobilization of the right leg. Log rolling every 2 hours is not directly related to promoting mobility in Buck's traction.