Nokea
On admission to the postpartal unit, the nurse's assessment identifies the client's fundus to be soft, 2 fingerbreadths above the umbilicus, and deviated to the right. This is most likely an indication of:
- A. Normal involution
- B. A full bladder
- C. An infection pain
- D. A hemorrhage
Correct Answer: B
Rationale: A boggy displaced uterus in the immediate postpartum period is a sign of urinary distention. Because uterine ligaments are stretched, a full bladder can displace the uterus.
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The nurse notes hyperventilation in a client with a thermal injury. She recognizes that this may be a reaction to which of the following medications if applied in large amounts?
- A. Neosporin sulfate
- B. Mafenide acetate
- C. Silver sulfadiazine
- D. Povidone-iodine
Correct Answer: B
Rationale: Mafenide acetate can cause metabolic acidosis, leading to compensatory hyperventilation. The other medications listed do not typically cause this reaction.
The intensive care unit is full and the emergency room just called to report that a client with suspected carbon monoxide poisoning has arrived. Which clinical manifestation would the nurse expect if carbon monoxide poisoning has occurred?
- A. Pulse oximetry reading of 80%
- B. Expiratory stridor and nasal flaring
- C. Cherry red color to the mucous membranes
- D. Presence of carbonaceous particles in the sputum
Correct Answer: C
Rationale: Carbon monoxide binds hemoglobin, forming carboxyhemoglobin, causing cherry red mucous membranes. Pulse oximetry (A) is unreliable, stridor (B) suggests obstruction, and carbonaceous particles (D) indicate smoke inhalation.
The client has an order for Garamycin (gentamicin) to be administered. Which lab test should be done before beginning the medication?
- A. Hematocrit
- B. Serum creatinine
- C. White cell count
- D. BUN
Correct Answer: B
Rationale: Gentamicin, an aminoglycoside, is nephrotoxic. Serum creatinine is monitored before administration to assess baseline kidney function, as impaired renal function increases toxicity risk. Hematocrit, white cell count, and BUN are less specific for gentamicin.
A client is admitted to the labor and delivery unit in active labor. The physician performs an amniotomy. Which observation would the nurse expect to make immediately after the amniotomy?
- A. Fetal heart tones 160 bpm
- B. Moderate uterine contractions
- C. A large amount of straw-colored fluid
- D. Thick green amniotic fluid
Correct Answer: C
Rationale: After an amniotomy the nurse expects to observe a large amount of clear or straw-colored amniotic fluid indicating normal amniotic fluid. Fetal heart tones of 160 bpm are normal but not specific to amniotomy contractions are unrelated and green fluid suggests meconium which is abnormal.
An elderly client is diagnosed with interstitial cystitis. Which finding differentiates interstitial cystitis from other forms of cystitis?
- A. The client is asymptomatic.
- B. The urine is free of bacteria.
- C. The urine contains blood.
- D. Males are affected more often.
Correct Answer: B
Rationale: Interstitial cystitis is characterized by chronic pelvic pain and urinary symptoms without bacterial infection, so the urine is typically free of bacteria, unlike bacterial cystitis.