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A postpartum nurse caring for a client who delivered vaginally 2 hours ago palpates the fundus and notes the character of the lochia. Which characteristic of the lochia should indicate to the nurse that the client's recovery is normal?
- A. Pink-colored lochia
- B. White-colored lochia
- C. Serosanguineous lochia
- D. Dark red-colored lochia
Correct Answer: D
Rationale: When checking the perineum, the lochia is monitored for amount, color, and the presence of clots. The color of the lochia during the fourth stage of labor (the first 1 to 4 hours after birth) is dark red. Options 1, 2, and 3 are not the expected characteristics of lochia at this time period.
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Tretinoin gel has been prescribed for a client with acne. What is the nurse's response when the client calls and reports that her skin has become very red and is beginning to peel?
- A. Discontinue the medication immediately.
- B. Come to the clinic immediately for an assessment.
- C. I'll notify your primary health care provider of these results.
- D. This is a normal occurrence with the use of this medication.
Correct Answer: D
Rationale: Tretinoin decreases cohesiveness of the epithelial cells, increasing cell mitosis and turnover. It is potentially irritating, particularly when used correctly. Within 48 hours of use, the skin generally becomes red and begins to peel. Options 1, 2, and 3 are incorrect statements to the client.
The nurse caring for a 5-year-old with a history of tetralogy of Fallot notes that the child has clubbed fingers. This finding is indicative of which associated condition?
- A. Tissue hypoxia
- B. Chronic hypertension
- C. Delayed physical growth
- D. Destruction of bone marrow
Correct Answer: A
Rationale: Clubbing, a thickening and flattening of the tips of the fingers and toes, is thought to occur because of chronic tissue hypoxia and polycythemia. Options 2, 3, and 4 do not cause clubbing.
The client states the need to use three pillows under the head and upper torso at night to be able to breathe comfortably while sleeping. The nurse documents that the client is experiencing which clinical finding?
- A. Orthopnea
- B. Dyspnea at rest
- C. Dyspnea on exertion
- D. Paroxysmal nocturnal dyspnea
Correct Answer: A
Rationale: Dyspnea is a subjective complaint that can range from an awareness of breathing to physical distress and does not necessarily correlate with the degree of heart failure. Dyspnea can be exertional or at rest. Orthopnea is a more severe form of dyspnea, requiring the client to assume a 'three-point' position while upright and use pillows to support the head and upper torso at night. Paroxysmal nocturnal dyspnea is a severe form of dyspnea occurring suddenly at night because of rapid fluid reentry into the vasculature from the interstitium during sleep.
The nurse analyzed an electrocardiogram (ECG) strip (refer to figure) for a client demonstrating left-sided heart failure and interprets the ECG strip as which rhythm?
- A. Atrial fibrillation
- B. Sinus dysrhythmia
- C. Ventricular fibrillation
- D. Third-degree heart block
Correct Answer: A
Rationale: Atrial fibrillation is characterized by rapid, chaotic atrial depolarization. Ventricular rates may be less than 100 beats per minute (controlled) or greater than 100 beats per minute (uncontrolled). The ECG reveals chaotic or no identifiable P waves and an irregular ventricular rhythm. A sinus dysrhythmia has a normal P wave and PR interval and QRS complex. In ventricular fibrillation, there are no identifiable P waves, QRS complexes, or T waves.
The nurse is scheduling a client for a series of diagnostic studies of the gastrointestinal (GI) system. Which of these studies should the nurse schedule last to avoid altering the results of the remaining tests?
- A. Ultrasound
- B. Colonoscopy
- C. Barium enema
- D. Computed tomography
Correct Answer: C
Rationale: When barium is instilled into the lower GI tract, it may take up to 72 hours to clear the GI tract. The presence of barium could cause interference with obtaining clear visualization and accurate results of the other tests listed if performed before the client has fully excreted the barium. For this reason, diagnostic studies that involve barium contrast are scheduled at the conclusion of other medical imaging studies.