Nokea
Thirty minutes after delivery the nurse finds that a mother's uterus is relaxed and the lochia is excessive.
The fist action by the nurse should be to:
- A. Check the mother's vital signs.
- B. Elevate the foot part of the bed.
- C. Immediately notify the physician.
- D. Massage the mother's uterus and expel any clots.
Correct Answer: D
Rationale: Massaging the uterus promotes contraction, reducing excessive lochia and preventing hemorrhage.
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A nurse is caring for a patient with diabetes mellitus who is scheduled for surgery. Which of the following is the most important preoperative assessment?
- A. Blood glucose level.
- B. Electrolyte levels.
- C. Complete blood count (CBC).
- D. Urinalysis.
Correct Answer: A
Rationale: Blood glucose control is critical preoperatively in diabetes to prevent complications like wound infections or ketoacidosis. Electrolytes, CBC, and urinalysis are important but secondary, as glucose directly impacts surgical outcomes.
Two days postpartum a patient who had a C-section delivery complains of pain in the right leg.
The nurse should instruct the patient to
- A. apply warm compresses.
- B. massage the affected area.
- C. encourage range of motion exercises to promote circulation.
- D. maintain bed rest and notifies the physician.
Correct Answer: D
Rationale: Leg pain post-C-section may indicate a deep vein thrombosis, requiring bed rest and physician notification.
A patient with borderline personality disorder is exhibiting self-harming behaviors. Which of the following interventions is most appropriate?
- A. Ignore the self-harming behaviors
- B. Provide immediate medical care for injuries
- C. Punish the patient for self-harming
- D. Encourage the patient to discuss their feelings
Correct Answer: B
Rationale: Providing immediate medical care for injuries ensures safety and addresses physical harm, the priority in self-harming behaviors. Ignoring, punishing, or only discussing feelings delays critical intervention.
The nurse administers prescribed pancreatin replacement therapy to Bonnie.
To effectively evaluate the effect of this treatment, should expect that this medication will result to
- A. Bulky, foul, smelly stools.
- B. Close to normal stools.
- C. Loose, frequent stools.
- D. Constipation.
Correct Answer: B
Rationale: Pancreatin aids fat digestion, resulting in near-normal stools in pancreatic insufficiency.
An adult had an open cholecystectomy and has an open wound. The client refuses to look at the area during the dressing change. What is the most likely reason for this behavior?
- A. Denial of surgery
- B. Change in body image
- C. The client fears becoming nauseated at the sight of the wound.
- D. The client does not like the sight of blood.
Correct Answer: B
Rationale: Refusing to look at the wound suggests difficulty accepting a change in body image post-cholecystectomy, a common emotional response.