Nokea
The nurse caring for a client who recently received an epidural anesthesia for a vaginal delivery suspects the presence of a vaginal hematoma. Which finding would be the best indicator of the presence of this type of hematoma?
- A. Changes in vital signs
- B. Signs of vaginal bruising
- C. Client reporting a tearing sensation
- D. Client reporting intense vaginal pressure
Correct Answer: A
Rationale: Changes in vital signs indicate hypovolemia in the anesthetized postpartum woman with a vaginal hematoma. Vaginal bruising may be present, but this may be a result of the delivery process and additionally is not the best indicator of the presence of a hematoma. Because the client received anesthesia, she would not feel pain or pressure.
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A 6-month-old has had a pyloromyotomy to correct a pyloric stenosis. Three days after surgery, the parents have placed their infant in his own infant seat (see fi gure). The nurse should do which of the following?
- A. Reposition the infant to the left side.
- B. Ask the parents to put the infant back in his crib
- C. Remind the parents that the infant cannot use a pacifier now.
- D. Tell the parents they have positioned their infant correctly
Correct Answer: D
Rationale: Following pyloromyotomy the infant should be positioned with the head elevated and slightly on the right side to promote gastric emptying; the parents have positioned their infant correctly. The infant should be positioned on the right side, not the left side. When the child is in a crib, the head can be elevated and the infant can be propped on the right side. The infant can use a pacifi er if needed.
A client in a cardiac rehabilitation program states that he would like to make sure he is eating the right foods to ensure adequate endurance on the treadmill. Which of the following nutrients is most helpful for promoting endurance during sustained activity?
- A. Protein.
- B. Carbohydrate.
- C. Fat.
- D. Water.
Correct Answer: B
Rationale: Carbohydrates are the primary energy source for sustained physical activity, providing glycogen stores for endurance.
A client has received a dose of dimenhydrinate. The nurse determines that the medication is effective when the client obtains relief of which problem?
- A. Chills
- B. Headache
- C. Ringing in the ears
- D. Nausea and vomiting
Correct Answer: D
Rationale: Dimenhydrinate is used to treat and prevent the symptoms of dizziness, vertigo, and nausea and vomiting that accompany motion sickness. None of the other options are associated with the described symptoms.
The nurse is assessing a client with suspected pulmonary edema. Which finding is most indicative?
- A. Dry cough.
- B. Crackles at lung bases.
- C. Clear breath sounds.
- D. Decreased respiratory rate.
Correct Answer: B
Rationale: Crackles at lung bases indicate fluid in the alveoli, a hallmark of pulmonary edema.
A client with a diagnosis of gout is prescribed indomethacin. The nurse should instruct the client to:
- A. Take the medication with food to reduce stomach upset.
- B. Avoid drinking alcohol.
- C. Limit fluid intake.
- D. Take the medication at bedtime only.
Correct Answer: A,B
Rationale: Taking indomethacin with food reduces gastrointestinal upset, and avoiding alcohol prevents uric acid buildup.