Nokea
The LPN is caring for all of the following women on the postpartum unit. Which situation requires further attention?
- A. A woman who gave birth four hours ago has red vaginal drainage on her perineal pad.
- B. The nurse palpates the uterine fundus 3 cm above the umbilicus in a woman who gave birth 12 hours ago.
- C. A woman who had a 20-hour labor and gave birth 8 hours ago asks the nurse not to bring her baby in for breastfeeding during the night.
- D. A woman who gave birth yesterday is sweating profusely and producing large amounts of urine.
Correct Answer: B
Rationale: A fundus 3 cm above the umbilicus 12 hours postpartum suggests uterine atony or retained clots, requiring further assessment to prevent hemorrhage. Other findings are normal or less urgent.
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The acute care clinic nurse administers a prescribed narcotic for a client with renal colic and then discharges the client without ensuring that the client has a designated driver. The client is subsequently involved in a motor vehicle accident causing injury to self and others. Which ethical principle did the nurse violate?
- A. Autonomy
- B. Nonmaleficence
- C. Paternalism
- D. Veracity
Correct Answer: B
Rationale: Nonmaleficence (do no harm) was violated by discharging the client under narcotic influence without ensuring safe transport, leading to harm. Autonomy, paternalism, and veracity are not primarily affected.
A client with cancer pain is prescribed oxycodone. Which information is most essential to reinforce in order to help prevent long-term complications?
- A. How to monitor blood pressure daily
- B. How to prevent constipation
- C. How to prevent itching
- D. How to prevent nausea
Correct Answer: B
Rationale: Constipation is a common, long-term complication of oxycodone, requiring preventive measures like fiber and fluids. Blood pressure monitoring, itching, and nausea are less critical long-term concerns.
Laboratory reference ranges
Hematocrit
Male: 42%-52%
(0.42-0.52)
Female: 37%-47%
(0.37-0.47)
Hemoglobin
Male: 14-18 g/dL
(140-180 g/L)
Female: 12-16 g/dL
(120-160 g/L)
The nurse is reviewing the chart of a client who has a traumatic below-the-knee amputation. Which client should the nurse see first?
- A. Female client who had an arthroscopic rotator cuff repair with sling immobilization and reports moderate swelling and tingling of the hand and fingers
- B. Female client who has a new cast and reports stinging of the hand and fingers and inability to move the toes
- C. Male client who has two new prosthetic legs applied after traumatic below-the-knee amputation and reports crushing pain in the amputated areas
- D. Male client who has a hematocrit of 37% (0.37) and hemoglobin of 12.5 g/dL (125 g/L) and is prescribed enoxaparin 1 day after a total hip arthroplasty
Correct Answer: A
Rationale: Stinging and inability to move toes in a new cast suggest compartment syndrome, a surgical emergency. Phantom limb pain and normal hematocrit/enoxaparin are less urgent.
The nurse is to administer a tuberculin skin test. At what angle should the needle be inserted?
- A. A 10-degree angle
- B. A 30-degree angle
- C. A 60-degree angle
- D. A 90-degree angle
Correct Answer: A
Rationale: A 10-degree angle ensures intradermal injection for a tuberculin skin test, creating a wheal for accurate reading.
Parents of a 7 year-old child call the clinic nurse because their daughter was sent home from school because of a rash. The child had been seen the day before by the provider and diagnosed with Fifth Disease (erythema infectiosum). What is the most appropriate action by the nurse?
- A. Tell the parents to bring the child to the clinic for further evaluation
- B. Refer the school officials to printed materials about this viral illness
- C. Inform the teacher that the child is receiving antibiotics for the rash
- D. Explain that this rash is not contagious and does not require isolation
Correct Answer: D
Rationale: Explain that this rash is not contagious and does not require isolation. Fifth Disease is not contagious once the rash appears, except in specific cases.