Nokea
The nurse is caring for a client immediately after a vaginal birth. The nurse notes that the client’s uterus is midline and boggy. Which of the following actions should the nurse take first?
- A. Perform uterine fundal massage
- B. Increase the rate of the oxytocin infusion
- C. Obtain the client’s blood pressure and pulse
- D. Check for pooled blood under the client’s buttocks
Correct Answer: A
Rationale: A boggy uterus indicates uterine atony, a major cause of postpartum hemorrhage. Fundal massage is the first action to stimulate contractions and expel clots. Adjusting oxytocin, checking vitals, or looking for blood are secondary after initiating massage.
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A 10-year-old weighs 99 lb (44.9 kg) and has a BMI of 24.8 kg/m² (>95th percentile). The licensed practical nurse (LPN) is collaborating with the registered nurse (RN) to formulate a weight loss plan. Which is most important for the nurse to determine?
- A. Child's pattern of daily physical activity
- B. Family's eating habits
- C. Family's financial resources for purchasing healthy foods
- D. Family's readiness for change
Correct Answer: D
Rationale: The family's readiness for change is critical, as it determines their willingness to adopt and sustain lifestyle changes necessary for weight loss. While activity, eating habits, and finances are important, motivation drives success.
The parents of a 4 year-old hospitalized child tell the nurse, 'We are leaving now and will be back at 6 PM.' A few hours later the child asks the nurse when the parents will come again. What is the best response by the nurse?
- A. They will be back right after supper.'
- B. In about 10 years, you will see them.'
- C. After you play awhile, they will be here.'
- D. When the clock hands are on 6 and 12.'
Correct Answer: A
Rationale: Time is not completely understood by a 4 year-old. Preschoolers interpret time with their own frame of reference. Thus, it is best to explain time in relationship to a known, common event.
The nurse is caring for a client with diabetes mellitus. The client is alert and oriented but appears shaky and pale. The client's capillary blood glucose level is 50 mg/dL (2.8 mmol/L). Which of the following actions should the nurse take next?
- A. Administer 1 mg glucagon IM to the client
- B. Give the client 4 oz (120 mL) of regular soda
- C. Prepare 50 mL of dextrose 50% in water IV push.
- D. Repeat the capillary blood glucose level to verify accuracy
Correct Answer: B
Rationale: A blood glucose of 50 mg/dL indicates hypoglycemia. Giving 4 oz of regular soda provides fast-acting carbohydrates to raise blood sugar quickly. Glucagon is used for severe hypoglycemia when the client is unresponsive, and repeating the test delays treatment.
The nurse is caring for a 4-year-old client with cystic fibrosis who uses a high-frequency chest wall oscillation (HFCWO) vest for chest physiotherapy. After reinforcing education with the client's parents, which statement by a parent requires further teaching?
- A. I will allow my child to have a snack while using the HFCWO vest to encourage cooperation.
- B. I will give my child the nebulized bronchodilator treatment during therapy with the HFCWO vest.
- C. I will perform manual chest percussion on my child if the HFCWO vest is broken or unavailable.
- D. My child will use the HFCWO vest once in the morning, once in the evening, and as needed.
Correct Answer: A
Rationale: Eating during HFCWO vest use can increase the risk of aspiration or reduce therapy effectiveness, indicating a need for further teaching. Bronchodilators during therapy, manual percussion as a backup, and the described frequency are appropriate.
The most suitable diet for the client with Meniere's disease is:
- A. High in animal protein
- B. Restricted in sodium
- C. High in fat-soluble vitamins
- D. Restricted in complex carbohydrates
Correct Answer: B
Rationale: A low sodium diet and nicotinic acid have been shown to be effective in reducing the symptoms of Meniere's disease. Answers A, C, and D are incorrect because they do not relieve the symptoms of Meniere's disease.