Nokea
The nurse is assessing a client who is 36 hours postpartum. Which of the following findings would indicate a need for further evaluation?
- A. Fundus firm and 2 cm below the umbilicus.
- B. Moderate lochia serosa.
- C. Mild perineal discomfort.
- D. Temperature of 100.4°F (38°C).
Correct Answer: D
Rationale: a temperature of 100.4°F may indicate infection, such as endometritis, and requires further evaluation
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The Joint Commission for Accreditation of Hospital Organizations (JCAHO) specifies that two client identifiers are to be used before administering medication. Which method is best for identifying patients using two patient identifiers?
- A. Take the medication administration record (MAR) to the room and compare it with the name and medical number recorded on the armband.
- B. Compare the medication administration record (MAR) with the client's room number and name on the armband.
- C. Request that a family member identify the client and then ask the client to state his name.
- D. Ask the client to state his full name and then to write his full name.
Correct Answer: A
Rationale: Comparing the MAR with the client's armband name and medical number ensures accurate identification using two reliable identifiers.
A client with pancreatitis has been transferred to the intensive care unit. The nurse assesses a pulmonary arterial wedge pressure (PAWP) of 14 mmHg. Based on this finding, the nurse would want to further assess for:
- A. A drop in blood pressure
- B. Rales on chest auscultation
- C. Complaints of chest pain
- D. Dry mucous membranes
Correct Answer: B
Rationale: A PAWP of 14 mmHg is slightly elevated, suggesting possible fluid overload, which could lead to pulmonary edema, indicated by rales on chest auscultation.
While reviewing the chart of a client with a history of hepatitis B, the nurse finds a serologic marker of HBsAg. The nurse recognizes that the client:
- A. Has chronic hepatitis B
- B. Has recovered from hepatitis B infection
- C. Has immunity to infection with hepatitis C
- D. Has no chance of spreading the infection to others
Correct Answer: A
Rationale: Presence of HBsAg indicates active hepatitis B infection, either acute or chronic, and potential infectivity.
A client with hepatitis C is scheduled for a liver biopsy. Which would the nurse include in the teaching plan?
- A. The client should lie on the left side after the procedure.
- B. Cleansing enemas should be given the morning of the procedure.
- C. Blood coagulation studies might be done before the biopsy.
- D. The procedure is noninvasive and causes no pain.
Correct Answer: C
Rationale: Hepatitis C increases bleeding risk, so coagulation studies are done before a liver biopsy to ensure safety. The client lies on the right side post-procedure, enemas aren't needed, and the procedure is invasive with some pain.
The nurse is caring for a Muslim client who is recovering from an automobile accident and is unable to cleanse herself after a bowel movement. Which of the following should the nurse do to show respect for the woman's cultural and religious beliefs?
- A. Use the left hand to cleanse the client's rectal area.
- B. Ask a female family member to assist the client.
- C. Wear gloves when cleansing the client's rectal area.
- D. Ask the client's husband to assist the client.
Correct Answer: B
Rationale: In Islamic culture, hygiene after defecation is important, and female clients may prefer assistance from female family members (B) to maintain modesty. The left hand (A) is traditionally used by the client, not the nurse. Gloves (C) are standard but not cultural. The husband (D) may not be appropriate due to modesty.