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During a shift change, a nurse is receiving a report for an adult female client who is postoperative. Which of the following client information should the nurse report?
- A. High platelets
- B. Hypertension
- C. Lower platelets
- D. High temperatures
Correct Answer: C
Rationale: Lower platelets can indicate a potential risk of bleeding in a postoperative client. Thrombocytopenia, or low platelet count, can lead to increased bleeding tendencies and should be promptly reported to the healthcare team for appropriate management. Monitoring platelet levels is crucial in postoperative care to prevent complications related to inadequate clotting ability.
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A charge nurse is recommending postpartum client discharge following a local disaster. Which of the following should the nurse recommend for discharge?
- A. A 42-year-old client who has preeclampsia and a BP of 166/110 mm Hg
- B. A 15-year-old client who delivered via emergency cesarean birth 1 day ago
- C. A client who received 2 units of packed RBCs 6 hr ago for a postpartum hemorrhage
- D. A client who delivered precipitously 36 hr ago and has a second-degree perineal laceration
Correct Answer: D
Rationale: The most appropriate client to recommend for discharge following a local disaster in the postpartum unit is the one who delivered precipitously 36 hours ago and has a second-degree perineal laceration. This client's condition is stable enough for discharge, and the timing and extent of the perineal laceration are within expectations for a safe discharge. Clients with conditions such as preeclampsia, recent emergency cesarean birth, or recent administration of packed RBCs for postpartum hemorrhage require further monitoring and care before being considered for discharge.
A healthcare professional is preparing to administer an autologous blood product to a client. Which of the following actions should the professional take to identify the client?
- A. Match the client's blood type with the type and cross-match specimens
- B. Confirm the provider's prescription matches the number on the blood component
- C. Ask the client to state their blood type and the date of their last blood donation
- D. Ensure that the client's identification band matches the number on the blood unit
Correct Answer: A
Rationale: When preparing to administer an autologous blood product, it is crucial to correctly identify the client to prevent errors. Matching the client's blood type with the type and cross-match specimens ensures that the blood product is intended for the correct recipient. This step helps in verifying the patient's identity and avoiding any transfusion-related complications. Confirming the blood type through type and cross-matching is a standard practice to ensure patient safety during blood transfusions.
When providing discharge teaching for a group of clients, a nurse should recommend a referral to a dietitian for which client?
- A. A client who has a prescription for warfarin and states, 'I will need to limit how much spinach I eat.'
- B. A client who has gout and states, 'I can continue to eat anchovies on my pizza.'
- C. A client who has a prescription for spironolactone and states, 'I will reduce my intake of foods that contain potassium.'
- D. A client who has osteoporosis and states, 'I'll plan to take my calcium carbonate with a full glass of water.'
Correct Answer: B
Rationale: The correct answer is the client who has gout and states, 'I can continue to eat anchovies on my pizza.' Gout is a condition that requires dietary modifications to manage symptoms. Anchovies are high in purines, which can exacerbate gout symptoms. Therefore, a referral to a dietitian is essential to provide appropriate dietary guidance for a client with gout. Clients on warfarin may need to monitor their vitamin K intake, particularly from foods like spinach. Clients taking spironolactone should be cautious about potassium-rich foods. Clients with osteoporosis should be educated on the proper administration of calcium supplements but do not necessarily need a dietitian referral for this specific statement.
A healthcare professional is preparing to assess a 2-week-old newborn. Which of the following actions should the professional plan to take?
- A. Obtain the newborn's body temperature using a tympanic thermometer.
- B. FACES pain scale.
- C. Auscultate the newborn's apical pulse for 60 seconds.
- D. Measure the newborn's head circumference over the eyebrows and below the occipital prominence.
Correct Answer: C
Rationale: Assessing the apical pulse in newborns is important to evaluate their cardiac function. The normal heart rate for a newborn is typically between 100-160 beats per minute. Auscultating the apical pulse for a full 60 seconds allows for an accurate assessment of the newborn's heart rate. This is a crucial component of the newborn assessment to ensure the baby's cardiovascular system is functioning within the expected range.
During physical therapy, a client with Parkinson's disease makes the following statements. Which statement indicates the need for a referral to physical therapy?
- A. ''I have been experiencing more tremors in my left arm than before''
- B. ''I noticed that I am having a harder time holding on to my toothbrush''
- C. ''Lately, I feel like my feet are freezing up, as they are stuck to the ground''
- D. ''Sometimes, I feel I am making a chewing motion when I'm not eating''
Correct Answer: C
Rationale: Feeling like the feet are freezing up and sticking to the ground is a common symptom of Parkinson's disease known as 'freezing of gait.' This symptom significantly impacts mobility and can be dangerous, indicating the need for specialized physical therapy interventions to address gait disturbances and improve mobility.