Nokea
Lochia serosa usually is evident on days 4 to 10 postpartum. When teaching the client about postpartum care, how should the nurse describe lochia serosa?
- A. Dark red discharge with small clots
- B. Yellowish discharge
- C. Pinkish to brownish discharge
- D. Clear watery discharge
Correct Answer: C
Rationale: Lochia serosa, days 4-10 postpartum, is pinkish to brownish (C) due to decreased blood and increased serous fluid. Dark red (A) is lochia rubra, yellowish (B) or clear (D) are not typical.
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The nurse is caring for a client with peripheral vascular disease. To correctly assess the oxygen saturation level, the monitor may be placed on the:
- A. Hip
- B. Ankle
- C. Earlobe
- D. Chin
Correct Answer: C
Rationale: The earlobe is a suitable site for pulse oximetry in peripheral vascular disease, as it is less affected by impaired peripheral circulation.
The nurse is caring for the client following a laryngectomy when suddenly the client becomes nonresponsive and pale, with a BP of 90/40. The initial nurse's action should be to:
- A. Place the client in Trendelenburg position
- B. Increase the infusion of normal saline
- C. Administer atropine intravenously
- D. Move the emergency cart to the bedside
Correct Answer: B
Rationale: Hypotension and unresponsiveness suggest hypovolemia or shock, so increasing the normal saline infusion is the initial action to restore volume.
The physician has ordered a blood test for H. pylori. The nurse should prepare the client by:
- A. Withholding oral intake after midnight
- B. Telling the client that no special preparation is needed
- C. Explaining that a small dose of radioactive isotope will be used
- D. Giving an oral suspension of glucose 1 hour before the test
Correct Answer: B
Rationale: A blood test for H. pylori requires no special preparation, such as fasting or administration of substances.
The primary cause of anemia in a client with chronic renal failure is:
- A. Poor iron absorption
- B. Destruction of red blood cells
- C. Lack of intrinsic factor
- D. Insufficient erythropoietin
Correct Answer: D
Rationale: Chronic renal failure reduces erythropoietin production by the kidneys, leading to decreased red blood cell production and anemia.
An ICU nurse monitors a client recovering from a head injury. The client's intracranial pressure (ICP) has been between 15 and 19 mmHg throughout the shift. However, after the nurse suctions the client's endotracheal tube, the ICP jumps to 28 mmHg. It decreases a few minutes later to 20 mmHg. The best intervention by the nurse is to
- A. increase the rate of the sedative IV drip.
- B. chart the findings and continue to monitor the client.
- C. reposition the client.
- D. contact the physician.
Correct Answer: D
Rationale: A sudden ICP spike to 28 mmHg post-suctioning suggests a significant issue (e.g., impaired cerebral perfusion). The physician should be contacted for evaluation.