Nokea
Shortly after the client was admitted to the postpartum unit, the nurse notes heavy lochia rubra with large clots. The nurse should anticipate an order for:
- A. Methergine
- B. Stadol
- C. Magnesium sulfate
- D. Phenergan
Correct Answer: A
Rationale: Methergine promotes uterine contractions to control postpartum hemorrhage, indicated for heavy lochia with clots.
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A 19-year-old female is admitted to the psychiatric floor after a suicide attempt 3 days ago. With client safety a priority, the nurse should
- A. assign the patient to the room closest to the nursing station.
- B. assign the patient to an open room with a roommate.
- C. assign the patient to a secluded, isolated room.
- D. assign a staff member to stay with the client at all times.
Correct Answer: A
Rationale: Placing the client near the nursing station allows close monitoring without isolation, balancing safety and autonomy. Constant staff presence is resource-intensive and not always necessary.
The nurse is supervising a student nurse on the oncology unit who is providing care for a client with neutropenic precautions. Which action by the student nurse requires intervention by the supervising nurse?
- A. Vital signs, including temperature, are monitored every 4 hours.
- B. The student nurse inspects the client's mouth at least every 8 hours.
- C. The student nurse delivers a potted plant to the room sent by the client's family.
- D. The student nurse washes her hands before performing client care or touching client belongings.
Correct Answer: C
Rationale: Potted plants pose an infection risk (e.g., mold) for neutropenic clients and are prohibited. Other actions are appropriate.
A transient homeless client with a history of mental illness and substance abuse is to be discharged. Which of the following support systems are most likely to provide social support for the client? Select all that apply.
- A. Self-help programs.
- B. Internet-based programs.
- C. Community agencies.
- D. Governmental agencies.
- E. Friends.
- F. Family.
Correct Answer: A,C,D
Rationale: Community agencies (C), governmental agencies (D), and self-help programs (A) are likely to provide social support for a homeless client with mental illness and substance abuse. Internet-based programs (B), friends (E), and family (F) may be less accessible or reliable.
The charge nurse overhears the patient care assistant speaking harshly to the client with dementia. The charge nurse should:
- A. Change the nursing assistant's assignment
- B. Explore the interaction with the nursing assistant
- C. Discuss the matter with the client's family
- D. Initiate a group session with the nursing assistant
Correct Answer: B
Rationale: Exploring the interaction addresses the behavior appropriately.
Which of the following are risk factors for developing glaucoma? Select all that apply.
- A. asthma
- B. pernicious anemia
- C. diabetes mellitus
- D. obesity
- E. hypertension
Correct Answer: C,E
Rationale: Diabetes mellitus and hypertension increase glaucoma risk by affecting ocular blood flow and pressure. Asthma, anemia, and obesity are not direct risk factors.