Nokea
The LPN is caring for a woman who delivered a healthy 7-lb baby boy 24 hours ago. Baseline vital signs were blood pressure (BP)=90/64, temperature (T)=97.6°F, pulse (P)=72, and respirations (R)=14. Which finding is of greatest concern?
- A. The woman has red vaginal drainage on her perineal pad.
- B. The woman complains of uterine cramping.
- C. The woman is drinking large amounts of water.
- D. The woman's vital signs are now BP=129/82, T=98.4°F, P=76, and R=16.
Correct Answer: D
Rationale: The significant rise in BP to 129/82 from 90/64 may indicate postpartum complications like preeclampsia, requiring immediate assessment. Red drainage, cramping, and increased water intake are normal postpartum findings.
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Which procedures are appropriate for the nurse to use when obtaining an adult client's blood for a laboratory test? Select all that apply.
- A. Avoid the arm on the affected side after a mastectomy
- B. Do not make further attempts to draw blood if unsuccessful on first 2 attempts
- C. If necessary to use an arm with IV infusing, draw proximal to infusion point
- D. Insert the needle bevel up at a 15-degree angle to the skin
- E. Obtain a finger capillary specimen from the middle of the finger pad
Correct Answer: A,B,C
Rationale: Avoiding the mastectomy side (A), limiting attempts to two (B), and drawing proximal to an IV (C) are correct. A 15-degree angle (D) is for IVs, not phlebotomy, and capillary samples avoid the finger pad center (E).
A pregnant client who is at 34 weeks gestation is diagnosed with a pulmonary embolism (PE). Which of these medications would the nurse anticipate the provider ordering?
- A. Oral Coumadin therapy
- B. Heparin 5000 units subcutaneously B.I.D.
- C. Heparin infusion to maintain the PTT at 1.5-2.5 times the control value
- D. Heparin by subcutaneous injection to maintain the PTT at 1.5 times the control value
Correct Answer: C
Rationale: Heparin infusion to maintain the PTT at 1.5-2.5 times the control value. In pregnant women with pulmonary embolism, heparin is preferred over warfarin due to warfarin's teratogenic effects. A continuous heparin infusion is typically used to achieve therapeutic anticoagulation, monitored by maintaining the PTT at 1.5-2.5 times the control value.
The clinic nurse is reinforcing client teaching about the tiotropium that has been prescribed for chronic obstructive pulmonary disease (COPD). Which statement indicates that the client has a correct understanding of this medication?
- A. A capsule holds the powdered medication that I put in a special inhaler.
- B. I do not need to rinse my mouth out with water after taking tiotropium.
- C. I have been taking tiotropium every time I have difficulty breathing.
- D. Tiotropium helps control my COPD by reducing inflammation in my airway.
Correct Answer: A
Rationale: Tiotropium is a powder in a capsule used with an inhaler (A). Rinsing the mouth (B) is unnecessary, but it's taken daily, not PRN (C), and it's a bronchodilator, not anti-inflammatory (D).
An adult comes to the physician's office with a history of headache yesterday and today and pain in the back. The nurse observes a horizontal band of pustular rash on the back extending from the spine to midline in the front. The client describes it as very painful. What would the nurse expect to be prescribed for this client?
- A. Antiviral
- B. Antibiotics
- C. Topical hydrocortisone
- D. Benadryl
Correct Answer: A
Rationale: The painful, unilateral, dermatomal pustular rash suggests herpes zoster (shingles), treated with antivirals like acyclovir.
Which nursing diagnosis is most appropriate for a client who has Cushing's syndrome?
- A. Risk for injury related to osteoporosis
- B. Pain related to cold intolerance
- C. Risk for deficient fluid volume related to excessive loss of sodium and water secondary to polyuria
- D. Risk for injury related to postural hypotension
Correct Answer: A
Rationale: Cushing's syndrome causes cortisol excess, leading to osteoporosis and increased fracture risk, making 'Risk for injury related to osteoporosis' the most appropriate diagnosis.