Nokea
Two days postpartum a patient who had a C-section delivery complains of pain in the right leg.
The nurse should instruct the patient to
- A. apply warm compresses.
- B. massage the affected area.
- C. encourage range of motion exercises to promote circulation.
- D. maintain bed rest and notifies the physician.
Correct Answer: D
Rationale: Leg pain post-C-section may indicate a deep vein thrombosis, requiring bed rest and physician notification.
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The nurse is caring for a client who had knee surgery this morning. Postoperative orders include a narcotic every three to four hours as needed for operative site pain and an ice bag. At 7:00 P.M., the client asks for pain medication. He was last medicated at 3:30 P.M. What is the best initial nursing action?
- A. Administer the prescribed analgesic
- B. Assess the location and nature of the pain
- C. Refill the ice bag as needed
- D. Reposition the client
Correct Answer: B
Rationale: Assessing pain location and nature ensures the medication is appropriate for operative site pain, guiding safe administration. Administering without assessment, refilling ice, or repositioning are premature.
A 17-year-old female was raped by a young man in her neighborhood. She is in the Emergency Department for evaluation and tests. After the procedure is completed, a rape crisis counselor (nurse specialist) talks to the client in a conference room regarding the rape. Implementing counseling by the nurse specialist for the raped victim represents:
- A. assessment.
- B. crisis intervention.
- C. empathetic concern.
- D. unwarranted intrusion.
Correct Answer: B
Rationale: Counseling by a rape crisis nurse specialist is a form of crisis intervention, providing immediate support to address the trauma. It is not merely assessment, empathy, or intrusion. Coordinated Care
A nurse is preparing to administer an intramuscular injection. Which of the following sites is most appropriate for an adult patient?
- A. Deltoid
- B. Vastus lateralis
- C. Dorsogluteal
- D. Ventrogluteal sites
Correct Answer: D
Rationale: The ventrogluteal site is safest for IM injections in adults, minimizing nerve or vessel damage. Deltoid and vastus lateralis are alternatives but less preferred, and dorsogluteal is avoided due to sciatic nerve risk.
The nurse is monitoring the contractions of a woman in labor. A contraction is recorded as beginning at 10:00 A.M and ending at 10:01 A.M. Another begins at 10:15 A.M. What is the frequency of the contractions?
- A. 14 minutes
- B. 10 minutes
- C. 15 minutes
- D. 9 minutes
Correct Answer: C
Rationale: 15 minutes. Frequency is measured from the start of one contraction to the start of the next.
A client has been taking perphenazine (Trilafon) by mouth for two days and now displays the following: head turned to the side, neck arched at an angle, stiffness and muscle spasms in neck. The nurse would expect to give which of the following as a PRN medication?
- A. Promazine (Sparine).
- B. Biperiden (Akineton).
- C. Thiothixene (Navane).
- D. Haloperidol (Haldol).
Correct Answer: B
Rationale: The symptoms describe acute dystonia, an extrapyramidal side effect of perphenazine. Biperiden, an antiparkinsonian agent, counteracts these effects. Promazine, thiothixene, and haloperidol (A, C, D) are antipsychotics and would not relieve dystonia.