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A postpartum client exhibits signs of severe dehydration, including dry mucous membranes, decreased skin turgor, and oliguria. Which nursing action is most appropriate?
- A. Administering intravenous fluids as ordered
- B. Offering oral rehydration solutions
- C. Providing education on fluid intake
- D. Notifying the healthcare provider immediately
Correct Answer: A
Rationale: Administering intravenous fluids as ordered is the most appropriate nursing action for a postpartum client exhibiting signs of severe dehydration. Severe dehydration, as indicated by dry mucous membranes, decreased skin turgor, and oliguria, requires immediate intervention to restore fluid balance effectively. Intravenous fluids deliver fluids directly into the bloodstream, ensuring rapid rehydration and addressing the critical situation promptly. Offering oral rehydration solutions may not be sufficient to address severe dehydration, and providing education on fluid intake can be important for prevention but is not the immediate priority in this scenario. Notifying the healthcare provider is essential, but initiating intravenous fluids promptly is crucial in managing severe dehydration.
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A patient presents with a painful, vesicular rash in a dermatomal distribution on the left thorax. The patient reports a history of chickenpox during childhood. Which of the following conditions is most likely responsible for this presentation?
- A. Herpes simplex virus infection
- B. Herpes zoster (shingles)
- C. Varicella (chickenpox)
- D. Impetigo
Correct Answer: B
Rationale: The presentation of a painful, vesicular rash in a dermatomal distribution on the left thorax, specifically in a patient with a history of chickenpox, is most suggestive of herpes zoster, commonly known as shingles. Herpes zoster is caused by the reactivation of the varicella-zoster virus, the same virus responsible for chickenpox. After a person recovers from chickenpox, the virus remains dormant in the nerve cells and can reactivate years later to cause shingles. The rash in herpes zoster typically progresses through different stages, including red patches leading to fluid-filled blisters. The characteristic rash typically appears unilaterally and is usually preceded by pain, burning, or tingling in the affected area. Unlike herpes simplex virus infection, which can cause similar lesions but is not typically localized to a specific dermatome, herpes zoster presents as a distinct unilateral cluster of vesicles along
A postpartum client who delivered a preterm infant expresses concerns about milk supply and worries about meeting the baby's nutritional needs. What nursing intervention should be prioritized to address the client's concerns?
- A. Providing education on techniques to enhance milk production and supply
- B. Recommending supplemental formula feedings to ensure adequate nutrition
- C. Encouraging the client to avoid breastfeeding until the infant reaches full term
- D. Referring the client to a dietitian for specialized nutritional support
Correct Answer: A
Rationale: Providing education on techniques to enhance milk production and supply should be prioritized to address the client's concerns about milk supply and meeting the baby's nutritional needs. By educating the client on proper breastfeeding techniques, frequent nursing sessions, skin-to-skin contact, and the importance of staying hydrated, the nurse can help promote successful breastfeeding and potentially increase milk production. Supplemental formula feedings are not the first line of intervention, as breastfeeding should be encouraged, especially for a preterm infant who may benefit significantly from breast milk. Encouraging the client to avoid breastfeeding until the infant reaches full term is not appropriate, as breastfeeding can still be beneficial for a preterm infant. Referring the client to a dietitian for specialized nutritional support may be beneficial, but addressing milk supply concerns through education should be prioritized initially to support breastfeeding success.
A woman in active labor is diagnosed with uterine rupture. What is the priority nursing action?
- A. Preparing for immediate cesarean section
- B. Administering intravenous oxytocin to augment contractions
- C. Assisting the mother into a hands-and-knees position
- D. Initiating cardiopulmonary resuscitation (CPR)
Correct Answer: A
Rationale: The priority nursing action for a woman diagnosed with uterine rupture during labor is to prepare for immediate cesarean section. Uterine rupture is a serious obstetric emergency that can lead to severe maternal and fetal complications, including hemorrhage, fetal distress, and injury to both mother and baby. A cesarean section is necessary to deliver the baby promptly and address any potential complications, such as controlling bleeding and ensuring the safety of both the mother and the baby. Time is critical in these situations, and prompt surgical intervention is essential to optimize outcomes. Administering intravenous oxytocin or assisting the mother into a hands-and-knees position would not address the immediate risks associated with uterine rupture. Initiating cardiopulmonary resuscitation (CPR) is only necessary if the mother's condition deteriorates to the point of cardiac or respiratory arrest, which may occur as a result of significant hemorrhage or other complications associated with uterine
A patient with chronic kidney disease presents with periorbital edema, hypertension, and proteinuria. Laboratory findings reveal elevated serum creatinine and urea levels, hyperkalemia, and metabolic acidosis. What is the most likely diagnosis?
- A. Nephrotic syndrome
- B. Diabetic nephropathy
- C. Acute glomerulonephritis
- D. Chronic kidney disease (CKD)
Correct Answer: D
Rationale: The constellation of symptoms presented (periorbital edema, hypertension, proteinuria) along with the laboratory findings (elevated creatinine and urea levels, hyperkalemia, metabolic acidosis) are classical signs of chronic kidney disease (CKD). In CKD, the kidneys gradually lose their function over time, leading to impaired filtration of waste products and electrolyte imbalance. The presence of hypertension and proteinuria are common in CKD due to the compromised renal function. Additionally, elevated serum creatinine and urea levels, hyperkalemia, and metabolic acidosis are indicative of kidney dysfunction.
Which of the following is a common complication associated with long-term use of corticosteroids in orthopedic patients?
- A. Osteoporosis
- B. Hypertension
- C. Hyperkalemia
- D. Hyperthyroidism
Correct Answer: A
Rationale: Osteoporosis is a common complication associated with long-term use of corticosteroids in orthopedic patients. Corticosteroids can lead to bone loss by inhibiting bone formation and promoting bone resorption, resulting in decreased bone mineral density and increased risk of fractures. Therefore, patients on long-term corticosteroid therapy, especially in high doses, should be monitored closely for osteoporosis and receive appropriate preventive measures such as calcium, vitamin D supplementation, and bisphosphonates to mitigate the risk of bone thinning and fractures.