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On a mother's 2nd postpartum day after having a vaginal delivery, the RN is preparing to assess her perineum and anus as part of her daily assessment. The best position for the client to be placed in for this assessment is:
- A. Sims'
- B. Fowler's
- C. Prone
- D. Any position that the RN chooses
Correct Answer: A
Rationale: The Sims' position allows optimal exposure of the perineum and anus for assessment by raising the upper buttocks.
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A client with a history of multiple myeloma is admitted with complaints of bone pain. The nurse should give priority to:
- A. Administering analgesics
- B. Monitoring for hypercalcemia
- C. Administering chemotherapy
- D. Monitoring blood pressure
Correct Answer: B
Rationale: Bone pain in multiple myeloma is often due to bone destruction, which can cause hypercalcemia, so monitoring for hypercalcemia is the priority.
A child sustains a supracondylar fracture of the femur. When assessing for vascular injury, the nurse should be alert for the signs of ischemia, which include:
- A. Bleeding, bruising, and hemorrhage
- B. Increase in serum levels of creatinine, alkaline phosphatase, and aspartate transaminase
- C. Pain, pallor, pulselessness, paresthesia, and paralysis
- D. Generalized swelling, pain, and diminished functional use with muscle rigidity and crepitus
Correct Answer: C
Rationale: Bleeding, bruising, and hemorrhage may occur due to injury but are not classic signs of ischemia. An increase in serum levels of creatinine, alkaline phosphatase, and aspartate transaminase is related to the disruption of muscle integrity. Classic signs of ischemia related to vascular injury secondary to long bone fractures include the five 'P's': pain, pallor, pulselessness, paresthesia, and paralysis. Generalized swelling, pain, and diminished functional use with muscle rigidity and crepitus are common clinical manifestations of a fracture but not ischemia.
A client with a history of liver cirrhosis is admitted with complaints of ascites. The nurse should give priority to:
- A. Monitoring for infection
- B. Administering pain medication
- C. Monitoring blood pressure
- D. Administering diuretics
Correct Answer: A
Rationale: Ascites increases infection risk (e.g., spontaneous bacterial peritonitis) in cirrhosis, so monitoring for infection is the priority.
When planning care for a 9-year-old client, the nurse uses which of the most effective means of helping siblings cope with their feelings about a brother who is terminally ill?
- A. Open discussion and understanding
- B. Play-acting out feelings in different roles
- C. Storytelling
- D. Drawing pictures
Correct Answer: B
Rationale: When dealing with grief, siblings are usually most comfortable initially with open discussion. Assuming different roles allows children to act out their feelings without fear of reprisals and to gain insight and control. This method may be helpful, but having the child take an active part through role playing is more effective. This technique may be helpful, but being an active participant through role playing is more effective.
The nurse is teaching a client with ulcerative colitis who has been prescribed sulfasalazine (Azulfidine). What clinical manifestations will the nurse tell the client to be particularly alert for when taking this drug?
- A. Flu-like symptoms
- B. Purplish rash
- C. Skin blisters
- D. Anorexia
- E. Nausea
Correct Answer: A, B, C, E
Rationale: Sulfasalazine side effects include flu-like symptoms (A), purplish rash (B), skin blisters (C), and nausea (E). Anorexia (D) is less common.