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A multipara client who delivered a female infant one hour ago. The nurse observes that the client's breasts are soft; the uterus is boggy, to the right of the midline, and 2 cm below the umbilicus; moderate lochia rubra.
It is MOST important for the nurse to take which of the following actions?
- A. Perform a straight catheterization.
- B. Offer the client the bedpan.
- C. Put the baby to breast.
- D. Massage the uterine fundus.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) encourage the client to void before catheterizing (2) correct-boggy uterus deviated to right indicates full bladder, encourage client to void (3) will increase uterine tone, but the problem is a full bladder (4) findings indicate a full bladder
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A client admitted to the psychiatric unit claims to be the 'Son of God' and insists that he will not be confined by 'mere mortals.' The most likely explanation for the client's delusions is:
- A. A religious conversion
- B. A stressful event
- C. Low self-esteem
- D. Overwhelming anxiety
Correct Answer: C
Rationale: Delusions of grandeur, like claiming to be the 'Son of God,' often stem from low self-esteem, compensating with inflated self-perception. Religious conversion, stress, or anxiety are less likely causes.
The nurse is making patient assignments on the obstetrical unit.
Which of the following patients should the nurse assign to an RN who has been reassigned to the obstetrical unit from outpatient surgery?
- A. A patient at 16 weeks gestation admitted with hyperemesis receiving IV fluids.
- B. A patient at 26 weeks gestation in premature labor receiving terbutaline (Brethine).
- C. A patient at 32 weeks gestation with a placenta previa and ruptured membranes.
- D. A patient at 37 weeks gestation with pregnancy-induced hypertension and epigastric pain.
Correct Answer: A
Rationale: Strategy: LPN/LVN and 'pulled' RN receive stable patients with expected outcomes. (1) correct-monitor IV therapy, administer antiemetics and nutritional supplements (2) monitor patient's response to medication and the status of the fetus (3) prepare for delivery, closely monitor fetal response (4) indicates impending seizures, prepare for delivery
An eight-month-old infant.
The nurse should look for which of the following in assessing pain in an eight-month-old infant?
- A. Decreased pulse rate.
- B. Increased fluid intake.
- C. Decreased respiratory rate.
- D. Rubbing a body part and crying.
Correct Answer: D
Rationale: Strategy: Think about each assessment. (1) pulse rate would increase (2) nonspecific regarding pain (3) does not reflect pain (4) correct-since an infant cannot talk, nurse needs to be aware of nonverbal signs of pain, such as rubbing the ear because of an earache
The nurse is to administer Lanoxin(digoxin) elixir to a 6-month old with a congenital heart defect. The nurse auscultates an apical pulse rate of 100 . The nurse should:
- A. Record the heart rate and call the physician.
- B. Record the heart rate and administer the medication.
- C. Administer the medication and recheck the heart rate in 15 minutes.
- D. Hold the medication and recheck the heart rate in 30 minutes.
Correct Answer: B
Rationale: A pulse of 100 in a 6-month-old is normal (80-150 bpm), so the nurse should administer digoxin . Calling the physician or holding the dose is unnecessary. Rechecking later is not standard.
The nurse is caring for a client with a history of falls.
- A. Which intervention should be included in the care plan for a client with a history of falls?
- B. Keep the bed in a high position to discourage getting out of bed.
- C. Encourage the client to remain in bed as much as possible.
- D. Place a night light in the bathroom.
- E. Restrict the client’s fluid intake in the evening.
Correct Answer: C
Rationale: A night light in the bathroom reduces fall risk by improving visibility during nighttime ambulation, a common time for falls. High bed positions and bed rest increase fall risk, and fluid restriction is unrelated to fall prevention.