Nokea
The nurse is collecting data from a client who delivered a full-term newborn vaginally 12 hours ago after prolonged labor. Which of the following findings would be essential to follow up?
- A. foul-smelling lochia
- B. external hemorrhoids
- C. temperature of 100 F (37.8 C)
- D. discomfort during fundal massage
Correct Answer: A
Rationale: Foul-smelling lochia suggests possible endometritis or infection, requiring immediate follow-up. External hemorrhoids and mild temperature elevation are common postpartum findings, and discomfort during fundal massage is expected unless accompanied by other concerning signs.
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Which of the following tasks can the practical nurse (PN) safely assign to an experienced unlicensed assistive personnel (UAP)? Select all that apply.
- A. Ambulate an oxygen-dependent client to the bathroom
- B. Check pulse oximetry for a client with respiratory rate 12/min
- C. Instruct a client with pneumonia on usage of the incentive spirometer
- D. Provide oral hygiene to a client with chronic obstructive pulmonary disease (COPD)
- E. Turn and reposition a client with pneumonia
Correct Answer: A,B,D,E
Rationale: UAP can ambulate stable clients , check pulse oximetry , provide oral hygiene , and reposition clients . Instructing on incentive spirometry requires nursing judgment and is not delegable.
The nurse is planning care for a client during the acute phase of a sickle cell vaso-occlusive crisis. Which of the following actions would be most appropriate?
- A. Fluid restriction 1000cc per day
- B. Ambulate in hallway 4 times a day
- C. Administer analgesic therapy as ordered
- D. Encourage increased caloric intake
Correct Answer: C
Rationale: Administer analgesic therapy as ordered. Pain management is critical during a sickle cell crisis.
The nurse understands that a priority goal of involuntary hospitalization of the severely mentally ill client is
- A. Re-orientation to reality
- B. Elimination of symptoms
- C. Protection from harm to self or others
- D. Return to independent functioning
Correct Answer: C
Rationale: Protection from harm to self or others. Involuntary hospitalization is required for individuals who are dangerous to themselves or others.
The nurse should monitor for which potential complication in a client receiving IV vancomycin and gentamicin?
- A. Blood in nasogastric tube drainage
- B. Decrease in red blood cell count
- C. Increase in serum creatinine level
- D. Onset of muscle aches and cramping
Correct Answer: C
Rationale: Vancomycin and gentamicin are nephrotoxic, so monitoring for increased serum creatinine is essential to detect kidney injury. GI bleeding , anemia , and muscle cramps are less directly related.
The nurse is planning a client care conference with the parents of a 3-year-old with newly diagnosed type 1 diabetes mellitus. What is the priority outcome for the caregivers?
- A. Demonstrating adequate coping skills
- B. Knowing how to keep blood sugars stable
- C. Understanding how to perform meal planning
- D. Understanding the need for periodic follow-up visits
Correct Answer: B
Rationale: The priority outcome for caregivers of a child with type 1 diabetes is knowing how to keep blood sugars stable , as this directly impacts the child's health and prevents complications. Coping , meal planning , and follow-up are important but secondary.