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When assessing a recently delivered multigravida client, the nurse finds that her vaginal bleeding is more than expected. Which factor in this client's history is related to this finding?
- A. The client delivered a large baby
- B. She is a gravida 6, para 5
- C. The client had a cesarean delivery
- D. The client had a prolonged labor
Correct Answer: B
Rationale: A client with a higher gravida and para count is at greater risk for uterine atony, which can lead to postpartum hemorrhage. The uterus may be less effective at contracting after multiple pregnancies, causing increased vaginal bleeding. Choices A, C, and D are incorrect because delivering a large baby, having a cesarean delivery, or experiencing prolonged labor do not directly correlate with an increased risk of postpartum hemorrhage in a multigravida client as compared to the gravida and para count.
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A client with chronic kidney disease is prescribed erythropoietin. What is the nurse's priority action?
- A. Monitor the client's hemoglobin and hematocrit.
- B. Monitor the client's blood pressure.
- C. Assess the client for signs of infection.
- D. Monitor the client for signs of bleeding.
Correct Answer: A
Rationale: The correct answer is A: 'Monitor the client's hemoglobin and hematocrit.' When a client with chronic kidney disease is prescribed erythropoietin, the nurse's priority action is to monitor the client's hemoglobin and hematocrit. Erythropoietin stimulates red blood cell production, so monitoring these lab values helps evaluate the effectiveness of erythropoietin in treating anemia. Monitoring the client's blood pressure (choice B) is important but not the priority in this scenario. Assessing the client for signs of infection (choice C) is important but not the priority related to the prescription of erythropoietin. Monitoring the client for signs of bleeding (choice D) is relevant but not the priority action when erythropoietin is prescribed.
Which information is a priority for the RN to reinforce to an older client after intravenous pyelography?
- A. Eat a light diet for the remainder of the day
- B. Rest for the next 24 hours as the preparation and the test are tiring
- C. Drink at least 1 8-ounce glass of fluid every waking hour for the next 2 days
- D. Measure the urine output for the next day and promptly notify the healthcare provider if it decreases
Correct Answer: D
Rationale: After intravenous pyelography, it is crucial for the client to measure urine output in the next day to monitor for any potential complications, such as kidney issues. Promptly notifying the healthcare provider in case of decreased urine output is essential for timely intervention. While rest and hydration are important post-procedure, monitoring urine output takes precedence due to its direct correlation with potential complications.
A female client taking prednisone reports feeling tired after stopping the corticosteroid abruptly. What is the priority nursing intervention?
- A. Auscultate breath sounds.
- B. Measure vital signs.
- C. Palpate the abdomen.
- D. Observe the skin for bruising.
Correct Answer: C
Rationale: The correct answer is to palpate the abdomen. When a client abruptly stops taking prednisone, there is a risk of adrenal insufficiency, which can present with symptoms like fatigue. Palpating the abdomen is crucial to assess for signs of adrenal crisis, such as abdominal pain, which can indicate severe adrenal insufficiency. Auscultating breath sounds (Choice A) and observing the skin for bruising (Choice D) are not the priority interventions in this situation. While measuring vital signs (Choice B) is important, palpating the abdomen takes precedence in this case to assess for potential adrenal insufficiency.
A client in labor who received epidural anesthesia experiences a sudden drop in blood pressure. What action should the nurse take first?
- A. Administer oxygen via nasal cannula.
- B. Administer an intravenous fluid bolus.
- C. Prepare the client for an emergency cesarean section.
- D. Place the client in a lateral position.
Correct Answer: D
Rationale: In a client experiencing a sudden drop in blood pressure after epidural anesthesia, the first action the nurse should take is to place the client in a lateral position. This position helps improve venous return and cardiac output by relieving aortocaval compression. Administering oxygen via nasal cannula may be necessary if the client shows signs of respiratory distress, but it is not the first priority in this situation. Administering an intravenous fluid bolus can help stabilize blood pressure, but repositioning the client takes precedence. Preparing the client for an emergency cesarean section is not indicated solely based on a sudden drop in blood pressure after epidural anesthesia; this step would be considered if other complications arise.
A client with a history of atrial fibrillation is prescribed warfarin. What is the nurse's priority teaching?
- A. Avoid eating foods high in potassium.
- B. Avoid foods high in vitamin K.
- C. Take the medication on an empty stomach.
- D. Take the medication at bedtime for best results.
Correct Answer: B
Rationale: The correct answer is B: 'Avoid foods high in vitamin K.' Warfarin is an anticoagulant medication that works by interfering with vitamin K-dependent clotting factors. Therefore, consuming foods high in vitamin K can affect the medication's effectiveness. Choices A, C, and D are incorrect because: A) Warfarin is not affected by foods high in potassium; C) Warfarin should be taken with food to minimize gastrointestinal side effects; D) There is no specific requirement for taking warfarin at bedtime for best results.