Nokea
The nurse teaches a postpartum client about postdelivery lochia. The nurse determines that the education has been effective when the client says that on the second day postpartum, the lochia should be which color?
- A. Red
- B. Pink
- C. White
- D. Yellow
Correct Answer: A
Rationale: The uterus rids itself of the debris that remains after birth through a discharge called lochia, which is classified according to its appearance and contents. Lochia rubra is dark red in color. It occurs from delivery to 3 days postpartum and contains epithelial cells, erythrocytes, leukocytes, shreds of decidua, and occasionally fetal meconium, lanugo, and vernix caseosa. Lochia serosa is a brownish pink discharge that occurs from days 4 to 10. Lochia alba is a white discharge that occurs from days 10 to 14. Lochia should not be yellow or contain large clots; if it does, the cause should be investigated without delay.
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An anxious client enters the emergency department seeking treatment for a laceration of the finger. The client's vital signs are pulse 106 beats per minute, blood pressure (BP) 158/88 mm Hg, and respirations 28 breaths per minute. After cleansing the injury and reassuring the client, the nurse rechecks the vital signs and notes a pulse of 82 beats per minute, BP 130/80 mm Hg, and respirations 20 breaths per minute. Which factor likely accounts for the change in vital signs?
- A. Cooling effects of the cleansing agent
- B. Client's adaptation to the air conditioning
- C. Early clinical indicators of cardiogenic shock
- D. Decline in sympathetic nervous system discharge
Correct Answer: D
Rationale: Physical or emotional stress triggers sympathetic nervous system stimulation. Increased epinephrine and norepinephrine cause tachycardia, high blood pressure, and tachypnea. Stress reduction then returns these parameters to baseline as the sympathetic discharge falls.
The nurse inserts an indwelling Foley catheter into the bladder of a postoperative client who has not voided for 8 hours and has a distended bladder. After the tubing is secured and the collection bag is hung on the bed frame, the nurse notices that 900 mL of urine has drained into the collection bag. What is the appropriate nursing action for the safety of this client?
- A. Check the specific gravity of the urine.
- B. Clamp the tubing for 30 minutes and then release.
- C. Provide suprapubic pressure to maintain a steady flow of urine.
- D. Raise the collection bag high enough to slow the rate of drainage.
Correct Answer: B
Rationale: Rapid emptying of a large volume of urine may cause engorgement of pelvic blood vessels and hypovolemic shock, prolapse of the bladder, or bladder spasms. Clamping the tubing for 30 minutes allows for equilibration to prevent complications. Option 1 is an assessment and would not affect the flow of urine or prevent possible hypovolemic shock. Option 3 would increase the flow of urine, which could lead to hypovolemic shock. Option 4 could cause backflow of urine. Infection is likely to develop if urine is allowed to flow back into the bladder.
A client with an extremity burn injury has undergone a fasciotomy. The nurse prepares to provide which type of wound care to the fasciotomy site?
- A. Dry sterile dressings
- B. Hydrocolloid dressings
- C. Wet, sterile saline dressings
- D. One-half-strength povidone-iodine dressings
Correct Answer: C
Rationale: A fasciotomy is an incision made extending through the subcutaneous tissue and fascia. The fasciotomy site is not sutured but is left open to relieve pressure and edema. The site is covered with wet sterile saline dressings. After 3 to 5 days, when perfusion is adequate and edema subsides, the wound is debrided and closed. A hydrocolloid dressing is not indicated for use with clean, open incisions. The incision is clean, not dirty, so there should be no reason to require povidone-iodine. Additionally, povidone-iodine can be irritating to normal tissues.
The nurse creates a discharge plan for a client diagnosed with peripheral neuropathy of the lower extremities. Which instructions should the nurse include in the plan? Select all that apply.
- A. Wear support or elastic stockings.
- B. Wear well-fitted shoes and walk barefoot when at home.
- C. Wear dark-colored stockings or socks and change them daily.
- D. Use a heating pad set at low setting on the feet if they feel cold.
- E. Apply lanolin or lubricating lotion to the legs and feet once or twice daily.
- F. Wash the feet and legs with mild soap and water and rinse and dry them well.
Correct Answer: A,E,F
Rationale: Peripheral neuropathy is any functional or organic disorder of the peripheral nervous system. Clinical manifestations can include muscle weakness, stabbing pain, paresthesia or loss of sensation, impaired reflexes, and autonomic manifestations. Home care instructions include wearing support or elastic stockings for dependent edema, applying lanolin or lubricating lotion to the legs and feet once or twice daily, washing the feet and legs with mild soap and water and rinsing and drying them well, inspecting the legs and feet daily and reporting any skin changes or open areas to the primary health care provider.
The nurse, caring for a client who has been placed in Buck's extension traction while awaiting surgical repair of a fractured femur, should perform a complete neurovascular assessment of the affected extremity that include which interventions? Select all that apply.
- A. Vital signs
- B. Bilateral lung sounds
- C. Pulse in the affected extremity
- D. Level of pain in the affected leg
- E. Skin color of the affected extremity
- F. Capillary refill of the affected toes
Correct Answer: C,D,E,F
Rationale: A complete neurovascular assessment of an extremity includes color, sensation, movement, capillary refill, and pulse of the affected extremity. Options 1 and 2 are not related to neurovascular assessment.