Nokea
The client is admitted with left-sided congestive heart failure. In assessing the client for edema, the nurse should check the:
- A. Feet
- B. Neck
- C. Hands
- D. Sacrum
Correct Answer: D
Rationale: In left-sided congestive heart failure, fluid backs up into the lungs, but dependent edema is assessed in the sacrum in bedridden clients or feet in ambulatory clients. The sacrum is the most appropriate site for hospitalized clients, as they are often recumbent.
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A client with a history of ulcerative colitis is admitted with complaints of bloody diarrhea. The nurse should give priority to:
- A. Monitoring for dehydration
- B. Administering pain medication
- C. Preparing for surgery
- D. Monitoring blood pressure
Correct Answer: A
Rationale: Bloody diarrhea in ulcerative colitis can cause significant fluid and electrolyte loss, so monitoring for dehydration is the priority.
A client with rheumatoid arthritis is beginning to develop flexion contractures of the knees. The nurse should tell the client to:
- A. Lie prone and let her feet hang over the mattress edge
- B. Lie supine, with her feet rotated inward
- C. Lie on her right side and point her toes downward
- D. Lie on her left side and allow her feet to remain in a neutral position
Correct Answer: A
Rationale: Lying prone with feet hanging over the mattress edge helps stretch the knee joints and prevent flexion contractures in rheumatoid arthritis. The other positions do not address knee extension.
A postpartum client complains of rectal pressure and severe pain in her perineum; this may be indicative of:
- A. Afterbirth pains
- B. Constipation
- C. Cystitis
- D. A hematoma of the vagina or vulva
Correct Answer: D
Rationale: Afterbirth pains are a common complaint in the postpartum client, but they are located in the uterus. Constipation may cause rectal pressure but is not usually associated with 'severe pain.' Cystitis may cause pain, but the location is different. Hematomas are frequently associated with severe pain and pressure. Further assessments are indicated for this client.
A client is admitted to the labor unit. On vaginal examination, the presenting part in a cephalic presentation was at station plus two. Station +2 means that the:
- A. Presenting part is 2 cm above the level of the ischial spines
- B. Biparietal diameter is at the level of the ischial spines
- C. Presenting part is 2 cm below the level of the ischial spines
- D. Biparietal diameter is 5 cm above the ischial spines
Correct Answer: C
Rationale: Station +2 means the presenting part is 2 cm below the ischial spines, indicating descent in the pelvis.
The client is admitted with a diagnosis of postpartum endometritis. Which symptom is most characteristic?
- A. Foul-smelling lochia
- B. Painless vaginal bleeding
- C. Fetal distress
- D. Maternal hypotension
Correct Answer: A
Rationale: Postpartum endometritis causes foul-smelling lochia due to uterine infection. Painless bleeding suggests other causes fetal distress is irrelevant postpartum and hypotension occurs only in severe cases.