Nokea
The nurse is caring for a client with a diagnosis of postpartum endometritis. Which intervention is most appropriate?
- A. Administer antibiotics
- B. Monitor fetal heart tones
- C. Prepare for cesarean delivery
- D. Administer tocolytics
Correct Answer: A
Rationale: Postpartumndometritis require es antibiotics to treat the uterine infection. Fetal heart tones are irrelevant postpartum cesarean delivery is not indicated and tocolytics are for preterm labor.
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A client with cancer is experiencing a common side effect of chemotherapy administration. Which laboratory assessment finding would cause the most concern?
- A. A sodium level of 50 mg/dL
- B. A blood glucose of 110 mg/dL
- C. A platelet count of 125,000/mm3
- D. A white cell count of 5,000/mm3
Correct Answer: A
Rationale: A sodium level of 50 mg/dL is impossible (likely a typo for 50 mEq/L, which is severely hyponatremic) and life-threatening, causing seizures. Glucose (B), platelets (C), and WBC (D) are near normal or less critical.
The nurse is planning room assignments for the day. Which client should be assigned to a private room if only one is available?
- A. The client with Cushing's disease
- B. The client with diabetes
- C. The client with acromegaly
- D. The client with myxedema
Correct Answer: A
Rationale: The client with Cushing’s disease may have immune suppression due to excess cortisol, increasing infection risk. A private room minimizes exposure to pathogens. Diabetes, acromegaly, and myxedema do not typically require isolation.
The nurse is caring for a client with a suspected stroke. Which assessment finding is most concerning?
- A. Mild headache
- B. Unilateral facial droop
- C. Slight dizziness
- D. Fatigue
Correct Answer: B
Rationale: Unilateral facial droop is a classic sign of stroke, indicating neurological deficit and requiring urgent evaluation. Headache (A), dizziness (C), and fatigue (D) are less specific.
Which of the following instructions should be included in the nurse's teaching regarding oral contraceptives?
- A. Weight gain should be reported to the physician.
- B. An alternate method of birth control is needed when taking antibiotics.
- C. If the client misses one or more pills,two pills should be taken per day for one week.
- D. Changes in the menstrual flow should be reported to the physician.
Correct Answer: B
Rationale: Antibiotics can reduce the effectiveness of oral contraceptives by altering gut flora necessitating an alternate birth control method during antibiotic use. Weight gain and menstrual changes are common and doubling pills is not the correct protocol for missed doses.
A client with a history of pulmonary embolism is admitted with complaints of chest pain. The nurse should give priority to:
- A. Administering anticoagulants
- B. Monitoring respiratory status
- C. Administering pain medication
- D. Monitoring blood pressure
Correct Answer: A
Rationale: Anticoagulants prevent further clot formation in pulmonary embolism, making them the priority to reduce complications.