Nokea
In the early postoperative period, the nurse notes a bright red, 3' x 5' area of drainage on the client's abdominal laparotomy dressing. What should be the nurse's first action in response to this observation?
- A. Ignore it because drainage is normal.
- B. Increase the I.V. flow rate.
- C. Take the client's vital signs.
- D. Change the dressing.
Correct Answer: C
Rationale: Bright red drainage suggests active bleeding, so taking vital signs to assess for hemodynamic instability is the priority.
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A client with a history of peptic ulcer disease is prescribed ranitidine (Zantac). The nurse should instruct the client to take the medication:
- A. With meals
- B. At bedtime
- C. Before breakfast
- D. After exercise
Correct Answer: B
Rationale: Ranitidine, an H2 receptor blocker, is most effective when taken at bedtime to reduce nighttime acid production and promote ulcer healing.
A client is receiving a blood transfusion when he begins to complain of difficulty breathing. The nurse notes an elevated blood pressure and a cough. Based on these signs, the nurse should prepare to manage which of the following complications?
- A. Anaphylactic reaction.
- B. Circulatory overload.
- C. Sepsis.
- D. Acute hemolytic reaction.
Correct Answer: B
Rationale: Difficulty breathing, elevated blood pressure, and cough suggest circulatory overload, a transfusion complication due to fluid volume excess.
Which of the following is the most accurate method of determining the extent of a client's fluid loss?
- A. Measuring intake and output
- B. Assessing vital signs
- C. Weighing the client
- D. Assessing skin turgor
Correct Answer: C
Rationale: Daily weighing is the most accurate method to assess fluid loss, as 1 kg of weight loss corresponds to 1 liter of fluid loss. Intake/output, vital signs, and skin turgor are less precise.
A nurse discusses with parents the procedures that will be performed on their neonate immediately after delivery. The nurse determines that the instructions have been understood when the client states that what will be done to the neonate first?
- A. The neonate will be suctioned.
- B. The neonate will be dried and stimulated.
- C. The neonate will be given oxygen.
- D. The neonate's umbilical cord will be cut.
Correct Answer: A
Rationale: Suctioning the neonate's airway is the first priority to ensure a clear airway and promote breathing immediately after delivery.
The administration of an intramuscular injection to a neonate should be given in the:
- A. Gluteus maximus muscle.
- B. Vastus lateralis muscle.
- C. Deltoid muscle.
- D. The sternocleidomastoid muscle.
Correct Answer: B
Rationale: The vastus lateralis is the preferred site for IM injections in neonates due to its large muscle mass and minimal risk of nerve or bone injury.