Nokea
The nurse is caring for a client post-total knee replacement. Which sign indicates a potential deep vein thrombosis?
- A. Calf swelling and pain
- B. Fever of 100°F (37.8°C)
- C. Mild incisional redness
- D. Joint stiffness
Correct Answer: A
Rationale: Calf swelling and pain are classic signs of deep vein thrombosis, a common postoperative complication requiring immediate evaluation.
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The nurse is caring for a client with an injury to the thalamus. The nurse should plan to:
- A. Give higher doses of pain medication.
- B. Keep patches on the client's eyes to prevent corneal abrasion.
- C. Monitor the temperature of the bathwater.
- D. Avoid turning the client.
Correct Answer: C
Rationale: The thalamus regulates body temperature, so an injury may impair thermoregulation. Monitoring bathwater temperature prevents burns or discomfort. Pain medication, eye patches, or avoiding movement are not directly related to thalamic injury.
After a client undergoes a contraction stress test that is negative, which of the following should the nurse assess next?
- A. Evidence of ruptured membranes.
- B. Viability status of the fetus.
- C. Indications that contractions have ceased.
- D. Fetal heart rate variability.
Correct Answer: C
Rationale: A negative contraction stress test indicates no fetal distress, so the nurse should next ensure contractions have ceased to prevent preterm labor. The other assessments are less immediate.
A primiparous client develops uterine atony and postpartum hemorrhage 1 hour after a vaginal delivery. The physician has ordered I.M. prostagland in F₂a. After administration of the medication, the nurse should observe the client for which of the following?
- A. Tachycardia
- B. Hypotension
- C. Constipation
- D. Fever
Correct Answer: A
Rationale: Prostaglandin-F2α can cause tachycardia as a side effect due to its stimulatory effects on smooth muscle. Hypotension, constipation, and fever are less commonly associated.
A newborn infant is diagnosed with imperforate anus. Which description of this disorder should the nurse provide to the parents?
- A. The presence of fecal incontinence
- B. Incomplete development of the anus
- C. The infrequent and difficult passage of dry stools
- D. Invagination of a section of the intestine into the distal bowel
Correct Answer: B
Rationale: Imperforate anus (anal atresia, anal agenesis) is the incomplete development or absence of the anus in its normal position in the perineum. Option 1 describes encopresis. Encopresis generally affects preschool and school-age children. Option 3 describes constipation. Constipation can affect any child at any time, although it peaks at age 2 to 3 years. Option 4 describes intussusception.
A client with a history of asthma is experiencing an acute exacerbation. Which medication should the nurse administer first?
- A. Albuterol
- B. Prednisone
- C. Montelukast
- D. Cromolyn sodium
Correct Answer: A
Rationale: Albuterol, a short-acting beta-agonist, is the first-line treatment for acute asthma exacerbations to relieve bronchospasm and improve airflow.