Nokea
Which nursing assessment indicates that involutional changes have occurred in a client who is 3 days postpartum?
- A. The fundus is firm and 3 finger widths below the umbilicus.
- B. The client has a moderate amount of lochia serosa.
- C. The fundus is firm and even with the umbilicus.
- D. The uterus is approximately the size of a small grapefruit.
Correct Answer: A
Rationale: A firm fundus 3 finger widths below the umbilicus by day 3 postpartum indicates normal uterine involution, as the uterus shrinks progressively after delivery.
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The nurse is caring for a client who is postoperative day 1 following a craniotomy. Which of the following positions should the nurse place the client in?
- A. Supine with the head of the bed flat.
- B. Semi-Fowler’s with the head elevated 30°.
- C. Prone with the head turned to one side.
- D. Trendelenburg with the head lowered.
Correct Answer: B
Rationale: semi-Fowler’s position with the head elevated 30° reduces intracranial pressure and promotes venous drainage
A nurse has received report on the day's clients. In planning morning rounds, which client is the priority to see?
- A. a new admission with a UTI and fever
- B. a client who is NPO for surgery later in the morning
- C. a client complaining of nausea after eating breakfast
- D. a client recently complaining of shortness of breath
Correct Answer: D
Rationale: Shortness of breath indicates a potential respiratory or cardiac issue, making this client the priority for immediate assessment.
The nurse is teaching the parents of a client with iron deficiency anemia about administering a liquid oral iron supplement. Which statement by the parents indicates that teaching was successful?
- A. We will give the iron through a straw.
- B. The iron should be given just before breakfast.
- C. We will give it with food to decrease stomach upset.
- D. We will mix the iron with a milkshake so it will taste better.
Correct Answer: A
Rationale: Using a straw minimizes tooth staining from liquid iron. Iron is best absorbed on an empty stomach, and milk can decrease absorption.
Which of the following ethnic groups has the highest risk of developing diabetes mellitus type 2 and should be routinely screened for diabetes?
- A. Hispanics
- B. Asians
- C. Caucasians
- D. African-Americans
Correct Answer: A
Rationale: Hispanics (A) have the highest risk for type 2 diabetes due to genetic and socioeconomic factors, requiring routine screening.
A vaginal exam reveals a footling breech presentation. The nurse should take which of the following actions at this time?
- A. Anticipate the need for a Caesarean section
- B. Apply an internal fetal monitor
- C. Place the client in Genu Pectoral position
- D. Perform an ultrasound
Correct Answer: A
Rationale: Footling breech presentation often requires a Caesarean section due to risks of cord prolapse and delivery complications.