Nokea
The nurse is caring for a client with a diagnosis of postpartum endometritis. Which vital sign change is most characteristic?
- A. Fever
- B. Tachycardia
- C. Hypotension
- D. All of the above
Correct Answer: A
Rationale: Fever is the most characteristic vital sign change in postpartum endometritis reflecting the underlying uterine infection. Tachycardia and hypotension occur only in severe cases.
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The nurse is assessing a client with suspected diabetic ketoacidosis. Which finding is most expected?
- A. Kussmaul respirations
- B. Hypertension
- C. Bradycardia
- D. Clear breath sounds
Correct Answer: A
Rationale: Kussmaul respirations (rapid, deep breathing) are a compensatory mechanism in diabetic ketoacidosis to eliminate excess carbon dioxide and correct acidosis. Hypotension, tachycardia, and clear breath sounds are more common.
The client with a history of preterm labor is being monitored at 28 weeks gestation. The physician orders betamethasone (Celestone). The rationale for administering betamethasone is to:
- A. Prevent infection
- B. Stimulate labor
- C. Enhance fetal lung maturity
- D. Prevent bleeding
Correct Answer: C
Rationale: Betamethasone a corticosteroid is given to women in preterm labor (24-34 weeks) to enhance fetal lung maturity by promoting surfactant production reducing the risk of respiratory distress syndrome. It does not prevent infection stimulate labor or prevent bleeding.
The client is admitted with left-sided congestive heart failure. In assessing the client for edema, the nurse should check the:
- A. Feet
- B. Neck
- C. Hands
- D. Sacrum
Correct Answer: D
Rationale: In left-sided congestive heart failure, fluid backs up into the lungs, but dependent edema is assessed in the sacrum in bedridden clients or feet in ambulatory clients. The sacrum is the most appropriate site for hospitalized clients, as they are often recumbent.
A client is placed on lithium therapy for her manic-depressive illness. When monitoring the client, the nurse assesses the laboratory blood values. Toxicity may occur with lithium therapy when the blood level is above:
- A. 1.0 mEq/L
- B. 2.2 mEq/L
- C. 0.03 mEq/L
- D. 1.5 mEq/L
Correct Answer: D
Rationale: This value is the level at which most clients are maintained, and toxicity may occur if the level increases. The client should be monitored closely for symptoms, because some clients become toxic even at this level.
An 83-year-old client has been hospitalized following a fall in his home. He has developed a possible fecal impaction. Which of the following assessment findings would be most indicative of a fecal impaction?
- A. Boardlike, rigid abdomen
- B. Loss of the urge to defecate
- C. Liquid stool
- D. Abdominal pain
Correct Answer: C
Rationale: Liquid stool can pass around an impaction, making it a key indicator. The other findings are not specific to fecal impaction.