Nokea
The client delivered a 9-pound infant two days ago. An effective means of managing discomfort from an episiotomy is:
- A. Medicated suppository
- B. Taking showers
- C. Sitz baths
- D. Ice packs
Correct Answer: C
Rationale: Sitz baths relieve episiotomy pain by promoting circulation and healing.
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The nurse gives a 35-year-old primigravida client a RhoGAM injection in her 27th week of pregnancy. Which of the following client situations requires the nurse to take this action?
- A. Rh-negative mother and Rh-positive father
- B. Rh-negative mother and Rh-negative father
- C. Rh-positive mother and Rh-negative father
- D. Rh-positive mother and Rh-positive father
Correct Answer: A
Rationale: RhoGAM is given to an Rh-negative mother with an Rh-positive father to prevent Rh incompatibility issues in the fetus.
A client is scheduled to undergo a bone marrow aspiration from the sternum. What position would the nurse assist the client into for this procedure?
- A. Dorsal recumbent
- B. Supine
- C. Fowler's
- D. Lithotomy
Correct Answer: B
Rationale: The supine position provides optimal access to the sternum for bone marrow aspiration and ensures client safety and comfort.
The doctor has prescribed Cortone (cortisone) for a client with systemic lupus erythematosis. Which instruction should be given to the client?
- A. Take the medication 30 minutes before eating.
- B. Report changes in appetite and weight.
- C. Wear sunglasses to prevent cataracts.
- D. Schedule a time to take the influenza vaccine.
Correct Answer: B
Rationale: Cortisone can cause weight gain and appetite changes, which should be monitored in SLE to manage side effects.
The physician has ordered a lumbar puncture for a client with suspected Guillain-Barre syndrome. The spinal fluid of a client with Guillain-Barre syndrome typically shows:
- A. Decreased protein concentration with a normal cell count
- B. Increased protein concentration with a normal cell count
- C. Increased protein concentration with an abnormal cell count
- D. Decreased protein concentration with an abnormal cell count
Correct Answer: B
Rationale: Guillain-Barre syndrome typically shows elevated protein levels in cerebrospinal fluid with a normal cell count, known as albuminocytologic dissociation.
The nurse has inserted a nasogastric tube and aspirated gastric contents to check the pH with color-coded pH paper. The aspirate is dark brown, and pH measures slightly less than 5 according to the color chart. What does this pH usually indicate?
- A. Gastric aspirate
- B. Intestinal aspirate
- C. Respiratory aspirate
- D. Inconclusive results
Correct Answer: A
Rationale: A pH < 5 with dark brown aspirate indicates gastric placement (A). Intestinal aspirate (B) has pH > 6, respiratory (C) is > 7, and results are conclusive (D).