Nokea
A postpartum client is experiencing heavy lochia 3 days after delivery. Which action should the nurse take first?
- A. Massage the fundus
- B. Administer oxytocin as ordered
- C. Encourage the client to ambulate
- D. Notify the physician
Correct Answer: A
Rationale: Heavy lochia may indicate uterine atony. Massaging the fundus is the first step to promote uterine contraction and reduce bleeding before escalating to other interventions.
You may also like to solve these questions
A client is suspected of having a slow gastrointestinal bleed. The nurse should evaluate the client for which sign or symptom?
- A. Increased pulse.
- B. Nausea.
- C. Tarry stools.
- D. Abdominal cramps.
Correct Answer: C
Rationale: Tarry stools are a hallmark sign of a slow gastrointestinal bleed due to digested blood.
The parents of a child with cystic fibrosis express concern about how the disease was transmitted to their child. The nurse should explain that:
- A. A disease carrier also has the disease.
- B. Two parents who are carriers may produce a child who has the disease.
- C. A disease carrier and an affected person will never have children with the disease.
- D. A disease carrier and an affected person will have a child with the disease.
Correct Answer: B
Rationale: Cystic fibrosis is an autosomal recessive disorder, meaning two carrier parents have a $25\%$ chance of having a child with the disease, as each parent can pass on the defective gene.
Which of the following data points about your client's hemodynamic values would you report to the doctor as abnormal?
- A. Pulmonary Artery Systolic Pressure: 22 mm Hg
- B. Pulmonary Artery Wedge Pressure: 22 mm Hg
- C. Pulmonary Artery Diastolic Pressure: 10 mm Hg
- D. Central Venous Pressure: 5 mm Hg
Correct Answer: B
Rationale: Normal ranges are: PAS 15-30 mmHg, PAWP 4-12 mmHg, PAD 4-12 mmHg, CVP 2-6 mmHg. PAWP of 22 mmHg is elevated, indicating potential left ventricular dysfunction or fluid overload.
The nurse notes that the client admitted after fainting is receiving olanzapine. Which disorder or condition should the nurse suspect the client is experiencing?
- A. Schizophrenia
- B. Dementia disorder
- C. Personality disorder
- D. Major depressive disorder
Correct Answer: A
Rationale: Olanzapine is an atypical antipsychotic medication used in the management of manifestations associated with psychotic disorders. It is the first-line treatment for schizophrenia, targeting both the positive and the negative symptoms. None of the remaining options are indicated uses for this medication.
Prochlorperazine (Compazine) is prescribed postoperatively. The nurse should evaluate the drug's therapeutic effect when the client expresses relief from which of the following?
- A. Nausea.
- B. Dizziness.
- C. Abdominal spasms.
- D. Abdominal distention.
Correct Answer: A
Rationale: Prochlorperazine is primarily used to treat postoperative nausea and vomiting, so relief from nausea indicates therapeutic effectiveness.