Nokea
History and Physical: Repeat caesarean birth 3 days ago, mastitis. Vital Signs: BP 130/84 mm Hg, HR 106/min, RR 20/min, Temp 38.94°C. Assessment: WBC 28,000/mm3, Hgb 13 g/dL, Hct 37%, redness/warmth in left breast, cracked nipples, body aches, chills, headache, breast tenderness.
The nurse is collecting data from the client 24 hr later. How should the nurse interpret the findings?
- A. Purulent nipple discharge: Sign of potential worsening condition
- B. Moderate lochia rubra: Unrelated to diagnosis
- C. Client reports decreased level of pain: Sign of potential improvement
- D. WBC count 35,000/mm3: Sign of potential worsening condition
- E. Temperature 38.4° C (101.1° F): Sign of potential improvement
- F. Hgb 12 g/dL: Unrelated to diagnosis
Correct Answer: A,C,D,E
Rationale: Purulent discharge and increased WBC suggest worsening mastitis, while decreased pain and lower temperature indicate improvement. Lochia and hemoglobin are unrelated to mastitis.
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- A. A client who has a positive pregnancy test
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- C. A client who has a history of gallbladder disease
- D. A client who is nulliparous
Correct Answer: A
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A nurse is reinforcing teaching about outpatient resources for a client who is recovering from a molar pregnancy.
Which of the following statements by the client indicates an understanding of the teaching?
- A. I will need to start chemotherapy immediately.
- B. I will need an amniocentesis within 1 month.
- C. I will need to attend a support group when I get home.
- D. I will need home palliative services after I am discharged from the hospital
Correct Answer: C
Rationale: A support group provides emotional support for the loss and concerns associated with a molar pregnancy.
A nurse is collecting data from a client who is at 28 weeks of gestation.
Which of the following findings is the nurse's priority?
- A. FHR 160/min
- B. Fundal height 24 cm
- C. Blood pressure 136/84 mm Hg
- D. Trace protein on urine reagent strip
Correct Answer: B
Rationale: A fundal height of 24 cm at 28 weeks is lower than expected, suggesting intrauterine growth restriction, requiring further evaluation.
A nurse is reviewing the facility protocol about newborn identification and safety with a new parent.
Which of the following information should the nurse include?
- A. We will scan your baby's identification bracelet each time we check on him.
- B. Your baby will wear an electronic bracelet when he is out of your room.
- C. We will match the bracelet on your baby with his footprint record each shift
- D. You should check the identity of individuals who come to remove your baby from the room.
Correct Answer: D
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A nurse is reinforcing teaching about travel with a client who is pregnant.
Which of the following instructions should the nurse include?
- A. Position the lap belt across your navel.
- B. Wear the shoulder harness snug across your stomach.
- C. Take a break and walk at least once every hour during long trips.
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Correct Answer: C
Rationale: Walking every hour during long trips improves circulation and reduces the risk of deep vein thrombosis.