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What physical assessment data should the nurse consider a normal finding for a primigravida client who is 12 hours postpartum?
- A. Soft, spongy fundus.
- B. Saturating two perineal pads per hour.
- C. Pulse rate of 56 BPM.
- D. Unilateral lower leg pain.
Correct Answer: C
Rationale: The correct answer is C: Pulse rate of 56 BPM. A normal finding for a primigravida client 12 hours postpartum would be a lower pulse rate as the body is recovering from childbirth. A pulse rate of 56 BPM is within the normal range for an adult.
A: Soft, spongy fundus would be a concerning finding as it could indicate uterine atony.
B: Saturating two perineal pads per hour would be excessive bleeding and could indicate postpartum hemorrhage.
D: Unilateral lower leg pain could be a sign of deep vein thrombosis, which is a potential complication postpartum.
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A 62-year-old male client with a history of coronary artery disease complains that his heart is 'racing' and he often feels dizzy. His blood pressure is 110/60, and he uses portable oxygen at 2 liters per nasal cannula. Based on the rhythm shown, which prescription should the nurse administer?
- A. Give magnesium via secondary infusion.
- B. Initiate IV heparin solution as per protocol.
- C. Administer IV adenosine (Adenocard).
- D. Prepare for synchronized cardioversion.
Correct Answer: C
Rationale: The correct answer is C: Administer IV adenosine (Adenocard).
Rationale:
1. The ECG rhythm shows regular narrow complex tachycardia, likely supraventricular tachycardia (SVT).
2. Adenosine is the first-line medication for terminating SVT by blocking conduction through the AV node.
3. Adenosine is given rapidly as a bolus dose followed by a saline flush to ensure quick delivery to the heart.
4. Adenosine has a very short half-life, making it safe to use in this scenario.
Summary:
A: Magnesium is not the first-line treatment for SVT.
B: Heparin is not indicated for the management of SVT.
D: Synchronized cardioversion is reserved for unstable patients with hemodynamic compromise, not indicated for stable SVT.
The client has just been diagnosed with Addison's disease. Which clinical manifestation should the nurse expect to find?
- A. Hypertension and hyperglycemia.
- B. Hyperpigmentation and hypotension.
- C. Exophthalmos and tachycardia.
- D. Weight gain and fluid retention.
Correct Answer: B
Rationale: The correct answer is B: Hyperpigmentation and hypotension. Addison's disease is characterized by adrenal insufficiency, leading to low cortisol and aldosterone levels. Hyperpigmentation occurs due to elevated levels of ACTH, causing melanin deposition. Hypotension results from aldosterone deficiency, leading to sodium and water loss. Choice A is incorrect because Addison's disease does not typically present with hypertension or hyperglycemia. Choice C is incorrect as exophthalmos and tachycardia are not typically associated with Addison's disease. Choice D is incorrect as weight gain and fluid retention are not common manifestations of Addison's disease.
A client with newly diagnosed diabetes mellitus is being discharged home. Which statement indicates the client understands the instructions about managing blood glucose levels?
- A. I will test my blood glucose level once a week.
- B. I should eat a snack if my blood glucose is 70 mg/dl.
- C. If I feel shaky, I should take another dose of insulin.
- D. It's okay to skip a meal if I'm not hungry.
Correct Answer: B
Rationale: The correct answer is B because eating a snack when blood glucose is 70 mg/dl helps prevent hypoglycemia. Testing blood glucose once a week (A) is not frequent enough for proper management. Taking extra insulin when shaky (C) can lead to hypoglycemia. Skipping meals (D) can cause unstable blood glucose levels.
In planning the turning schedule for a bedfast client, it is most important for the nurse to consider what assessment finding?
- A. 4+ pitting edema of both lower extremities.
- B. A Braden risk assessment scale rating score of ten.
- C. Warm, dry skin with a fever of 100‚° F.
- D. Hypoactive bowel sounds with infrequent bowel movements.
Correct Answer: B
Rationale: The correct answer is B: A Braden risk assessment scale rating score of ten. This is crucial because the Braden scale assesses the client's risk for developing pressure ulcers. A score of ten indicates a very high risk, requiring frequent repositioning to prevent pressure ulcers.
Choice A is incorrect because 4+ pitting edema of both lower extremities indicates fluid overload, not directly related to turning schedule planning.
Choice C is incorrect because warm, dry skin with a fever of 100‚° F suggests a possible infection, but does not affect the need for turning schedule planning.
Choice D is incorrect as hypoactive bowel sounds and infrequent bowel movements are related to gastrointestinal function, not directly impacting the turning schedule.
When a client reports being allergic to penicillin, which question should the nurse ask to gather more information?
- A. Are you allergic to any other medications?
- B. How often have you taken penicillin in the past?
- C. Is anyone else in your family allergic to penicillin?
- D. What happens to you when you take penicillin?
Correct Answer: D
Rationale: Rationale: Option D is the correct answer because it directly addresses the client's experience with penicillin, providing crucial details about the allergic reaction. By asking what happens when the client takes penicillin, the nurse gains specific information to assess the severity and type of allergic reaction. This helps in determining appropriate interventions and alternative medications. Options A, B, and C are incorrect as they do not focus on gathering detailed information about the client's allergic reaction to penicillin. Option A is too broad, option B is not relevant to the current situation, and option C does not directly address the client's individual experience.