Nokea
The nurse is reinforcing discharge teaching for a client who had aortic valve replacement with a mechanical heart valve. Which statement by the client indicates that teaching has been effective?
- A. I'm glad that I can continue taking my Ginkgo biloba.
- B. I will increase my intake of leafy green vegetables
- C. I will start applying vitamin E to my chest incision after showering
- D. I will shave with an electric razor from now on
Correct Answer: D
Rationale: Mechanical prosthetic valves are more durable than biological valves but require long-term anticoagulation therapy due to the increased risk of thromboembolism. The client should be taught ways to reduce the risk of bleeding.
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Which of these women in the labor and delivery unit would the nurse check first when the water breaks (ROM) for all of them within a 2 minute period?
- A. A multigravida with station at +2, contractions at 15 minutes apart with duration of 30 seconds, cervix dilated at 7 cm, and 50% effacement
- B. A multigravida with station at -1, contractions at 15 minutes apart with duration of 30 seconds, cervix dilated at 3 cm, and 10% effacement
- C. A primipara with station at 0, contractions at 20 minutes apart with duration of 20 seconds, cervix dilated at 2 cm and 10% effacement
- D. A primipara with station at 1, contractions at 15 minutes apart with duration of 35 seconds, cervix dilated at 5 cm and 50% effacement
Correct Answer: B
Rationale: A multigravida with station at -1, contractions at 15 minutes apart with duration of 30 seconds, cervix dilated at 3 cm, and 10% effacement. When the station is -1 or -2 and the water breaks, the risk is greater for a prolapsed cord.
The nurse on a pediatric unit is caring for a 2-year-old client. Which of the following interventions are appropriate to reduce the distress of hospitalization on the child? Select all that apply.
- A. Encourage the parent to leave the child alone for short intervals
- B. Follow the child’s home sleep schedule and routine
- C. Integrate preferred snack foods into the child’s routine
- D. Point out body changes that may occur
- E. Provide various options when choosing toys
Correct Answer: B,C,E
Rationale: Maintaining sleep routines, offering preferred snacks, and providing toy choices reduce distress by promoting familiarity and autonomy. Leaving alone or discussing body changes may increase anxiety.
The LPN is caring for all of the following women on the postpartum unit. Which situation requires further attention?
- A. A woman who gave birth four hours ago has red vaginal drainage on her perineal pad.
- B. The nurse palpates the uterine fundus 3 cm above the umbilicus in a woman who gave birth 12 hours ago.
- C. A woman who had a 20-hour labor and gave birth 8 hours ago asks the nurse not to bring her baby in for breastfeeding during the night.
- D. A woman who gave birth yesterday is sweating profusely and producing large amounts of urine.
Correct Answer: B
Rationale: A fundus 3 cm above the umbilicus 12 hours postpartum suggests uterine atony or retained clots, requiring further assessment to prevent hemorrhage. Other findings are normal or less urgent.
After receiving shift report, the nurse is assessing a client started on trimethoprim-sulfamethoxazole 2 days ago for treatment of a urinary tract infection. The client reports itching, and the nurse notices a diffuse maculopapular rash on the client's face. What should the nurse do first?
- A. Administer diphenhydramine
- B. Administer injectable epinephrine
- C. Examine the client's trunk and limbs
- D. Reassess the client's allergy history
Correct Answer: C
Rationale: Examining the trunk and limbs determines the rash’s extent, guiding whether it’s a mild reaction or a severe one (e.g., Stevens-Johnson syndrome). Diphenhydramine, epinephrine, or allergy reassessment are secondary until the rash is fully assessed.
The nurse is caring for a client with diabetic ketoacidosis (DKA). Which of the following acid-base imbalances would the nurse expect to assess in this client?
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Respiratory acidosis
- D. Respiratory alkalosis
Correct Answer: A
Rationale: DKA causes metabolic acidosis due to excess ketone production from fat breakdown. Alkalosis and respiratory imbalances are not typical in DKA.