Nokea
The nurse is reviewing the records of recently admitted clients to the postpartum unit. The nurse determines that which clients would have an increased risk for developing a puerperal infection? Select all that apply.
- A. A client with a history of previous infections
- B. A client who has given birth to a set of twins
- C. A client who had numerous vaginal examinations
- D. A client who has experienced three previous miscarriages
- E. A client who underwent a vaginal delivery of the newborn
- F. A client who experienced prolonged rupture of the membranes
Correct Answer: A,C,F
Rationale: Risk factors associated with puerperal infection include a history of previous infections, excessive number of vaginal examinations, cesarean births, prolonged rupture of the membranes, prolonged labor, trauma, and retained placental fragments. A vaginal delivery, a history of miscarriages, and the delivery of twins are not considered as risk factors for developing a puerperal infection.
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An adolescent is admitted to the orthopedic nursing unit after spinal rod insertion for the treatment of scoliosis. Which assessments are most important in the immediate postoperative period when considering the client's neurovascular status? Select all that apply.
- A. Pain level
- B. Urinary output
- C. Ability to move all extremities
- D. Capillary refill in all extremities
- E. Ability to flex and extend the feet
- F. Ability to detect sensations in all extremities
Correct Answer: C,D,E,F
Rationale: When the spinal column is manipulated during surgery, altered neurovascular status is a possible complication; therefore, neurovascular checks, including circulation, sensation, and motion, should be done at least every 2 hours. Level of pain and urinary output are important postoperative assessments, but neurovascular status is more important.
The nurse provides information to a client with a colostomy. When discussing measures to help manage colostomy odors, the nurse will encourage the client to regularly consume which foods? Select all that apply.
- A. Parsley
- B. Yogurt
- C. Buttermilk
- D. Cucumbers
- E. Cauliflower
- F. Cranberry juice
Correct Answer: A,B,C,F
Rationale: The nurse should provide information about foods and measures that will prevent odor from a colostomy. Parsley, yogurt, buttermilk, and cranberry juice will prevent odor. Charcoal filters, pouch deodorizers, or placement of a breath mint in the pouch will also eliminate odors. Foods that cause flatus and thus odor, including broccoli, Brussels sprouts, cabbage, cauliflower, cucumbers, mushrooms, and peas, should be avoided.
The nurse is counseling the family of a terminally ill client about palliative care. The nurse identifies which goals as being those of palliative care? Select all that apply.
- A. The delay of the impending death
- B. Offering a caring support system
- C. Providing measure focused on pain management
- D. Introduction of interventions that enhance the quality of life
- E. Expanding the focus of care to both the client and the family
- F. Addressing the expressed spiritual needs of the client and the family
Correct Answer: B,C,D,E,F
Rationale: Palliative care is a philosophy of total care. Palliative care goals include the following: offering a support system to help the client live as actively as possible until death; providing relief from pain and other distressing symptoms; enhancing the quality of life; offering a support system to help families cope during the client's illness and their own bereavement; affirming life and regarding dying as a normal process, neither hastening nor postponing death; and integrating psychological and spiritual aspects of client care.
A client who experienced repeated pleural effusions from inoperable lung cancer is to undergo pleurodesis. What intervention should the nurse plan to implement after the primary health care provider injects the sclerosing agent through the chest tube to help assure the effectiveness of the procedure?
- A. Ambulate the client.
- B. Clamp the chest tube.
- C. Ask the client to cough and deep breathe.
- D. Ask the client to remain in a side-lying position.
Correct Answer: B
Rationale: After injection of the sclerosing agent, the chest tube is clamped to prevent the agent from draining back out of the pleural space. Depending on primary health care provider preference, a repositioning schedule is used to disperse the substance. Ambulation, coughing, and deep breathing have no specific purpose in the immediate period after injection.
The nurse is caring for a 33-week pregnant client who has experienced a premature rupture of the membranes (PROM). Which interventions should the nurse expect to be part of the plan of care? Select all that apply.
- A. Perform frequent biophysical profiles.
- B. Monitor for elevated serum creatinine.
- C. Monitor for manifestations of infection.
- D. Teach the client how to count fetal movements.
- E. Use strict sterile technique for vaginal examinations.
- F. Inform the client about the need for tocolytic therapy.
Correct Answer: A,C,D,E
Rationale: Premature rupture of membranes (PROM) increases the risk of infection, preterm labor, and fetal compromise. Frequent biophysical profiles assess fetal well-being. Monitoring for manifestations of infection is critical due to the risk of chorioamnionitis. Teaching the client to count fetal movements helps monitor fetal activity and detect potential distress. Strict sterile technique for vaginal examinations minimizes infection risk. Monitoring serum creatinine is not directly related to PROM management. Tocolytic therapy may be considered but is not universally required unless preterm labor is confirmed.