Nokea
A nurse is providing care to a group of postpartum clients. Which client comment should prompt further investigation?
- A. I feel so exhausted that I started taking naps when the baby sleeps.
- B. I have trouble sleeping well at night because I worry that I won't hear the baby cry.
- C. My aunt has come over every day to care for the baby because the baby's cries bother me.
- D. My spouse thinks that I have been more emotional since I had the baby last week.
Correct Answer: C
Rationale: Being bothered by the baby's cries (C) may indicate postpartum depression, requiring investigation. Exhaustion (A), worry (B), and emotionality (D) are common postpartum experiences.
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Which procedures are appropriate for the nurse to use when obtaining an adult client's blood for a laboratory test? Select all that apply.
- A. Avoid the arm on the affected side after a mastectomy
- B. Do not make further attempts to draw blood if unsuccessful on first 2 attempts
- C. If necessary to use an arm with IV infusing, draw proximal to infusion point
- D. Insert the needle bevel up at a 15-degree angle to the skin
- E. Obtain a finger capillary specimen from the middle of the finger pad
Correct Answer: A,B,C
Rationale: Avoiding the mastectomy side (A), limiting attempts to two (B), and drawing proximal to an IV (C) are correct. A 15-degree angle (D) is for IVs, not phlebotomy, and capillary samples avoid the finger pad center (E).
The nurse is monitoring a client who had an esophagogastroduodenoscopy 2 hours ago. Which finding requires an immediate report to the registered nurse?
- A. Blood pressure drop from 122/88 mm Hg to 106/72 mm Hg
- B. Gag reflex has not returned
- C. Sore throat when swallowing
- D. Temperature spike to 101.2 F (38.4 C)
Correct Answer: D
Rationale: A temperature spike to 101.2 F (D) suggests possible perforation or infection, requiring immediate reporting. BP drop (A) is mild, absent gag reflex (B) is expected, and sore throat (C) is normal post-procedure.
A client who had a total knee replacement is to be discharged today. Which statement that the client makes indicates a need for further instruction?
- A. When I am walking, I will wear that ugly immobilizer.'
- B. I will sit with my leg elevated.'
- C. I think I understand how to use the continuous passive motion machine.'
- D. I won't put any weight at all on my affected leg.'
Correct Answer: D
Rationale: Total knee replacement typically allows partial weight-bearing with assistance post-surgery; complete non-weight-bearing suggests misunderstanding of mobility instructions.
A client is admitted for removal of a goiter. Which nursing intervention should receive priority during the post-operative period?
- A. Maintaining fluid and electrolyte balance
- B. Assessing the client's airway
- C. Providing needed nutrition and fluids
- D. Providing pain relief with narcotic analgesics
Correct Answer: B
Rationale: A goiter is hyperplasia of the thyroid gland. Removal of a goiter can result in laryngeal spasms and airway occlusion. The other answers are lesser in priority.
The nurse is caring for a 10-year-old client with sickle cell disease who is experiencing an episode of acute pain. Which of the following diversional activities would be appropriate for the nurse to offer the client?
- A. putting together a puzzle in the activity room
- B. reading an age-appropriate book
- C. walking down the unit hallways
- D. playing with finger puppets
Correct Answer: B
Rationale: Reading a book (B) is a calm, stationary activity suitable for pain management. Puzzles (A) may require movement, walking (C) could worsen pain, and puppets (D) may be too childish for a 10-year-old.