Nokea
When performing an assessment on a mother who just delivered a healthy newborn, the nurse should expect to note that the fundus is positioned at which location?
- A. To the right of the abdomen
- B. At the level of the umbilicus
- C. Above the level of the umbilicus
- D. One fingerbreadth above the symphysis pubis
Correct Answer: B
Rationale: Immediately after delivery, the uterine fundus should be at the level of the umbilicus or one to three fingerbreadths below it and in the midline of the abdomen. A fundus that is not located in the midline may indicate a full bladder. If the fundus is above the umbilicus, this may indicate that blood clots in the uterus need to be expelled by fundal massage.
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A client with severe major depression states, 'My heart has stopped and my blood is black ash.' The nurse interprets this statement to be evidence of which of the following?
- A. Hallucination.
- B. Illusion.
- C. Delusion.
- D. Paranoia.
Correct Answer: C
Rationale: The client's statement reflects a false, fixed belief that is not based in reality, which is characteristic of a delusion. Hallucinations involve sensory perceptions, illusions are misinterpretations of stimuli, and paranoia involves suspicion, none of which fit this scenario.
A client with a history of systemic lupus erythematosus (SLE) reports joint pain and fatigue. Which intervention should the nurse prioritize?
- A. Administer analgesics as ordered
- B. Encourage high-impact exercise
- C. Apply cold packs to joints
- D. Restrict fluid intake
Correct Answer: A
Rationale: Administering analgesics addresses joint pain, a common SLE symptom, improving comfort and quality of life.
The nurse is caring for a client with a history of atrial fibrillation who is prescribed amiodarone (Cordarone). Which of the following side effects should the nurse monitor for?
- A. Pulmonary toxicity.
- B. Hyperglycemia.
- C. Weight gain.
- D. Hair loss.
Correct Answer: A
Rationale: Amiodarone can cause pulmonary toxicity, a serious side effect requiring regular monitoring of lung function.
A client with chronic renal failure is receiving epoetin alfa (Epogen). The nurse should monitor the client for which of the following adverse effects?
- A. Hypertension.
- B. Hypoglycemia.
- C. Bradycardia.
- D. Hypokalemia.
Correct Answer: A
Rationale: Epoetin alfa can cause hypertension due to increased red blood cell production and blood viscosity, requiring close monitoring.
The nurse is assessing home care needs for a group of clients. Which clients qualify for home care services? The client who? Select all that apply.
- A. Requires monitoring of prothrombin time due to Coumadin (warfarin) therapy.
- B. Has episodes of vertigo that result in falls.
- C. Has multiple sclerosis with an open, draining lesion on a foot.
- D. Needs stronger lenses for glasses.
Correct Answer: A,B,C
Rationale: Clients requiring prothrombin time monitoring, those with vertigo causing falls, and those with open lesions qualify for home care due to medical needs. Needing glasses does not typically require skilled home care services.