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Which of the following is least appropriate when caring for a stable postpartum client?
- A. Assess the location and height of the fundus.
- B. Conduct a family assessment, including the mother's future plans for going back to work, if applicable.
- C. Monitor the client for bleeding.
- D. Provide perineal care.
Correct Answer: B
Rationale: A family assessment is more appropriate after the client(s) have been discharged from the hospital. In the immediate postpartum stage, the nurse should provide perineal care, monitor for bleeding, and assess the location and height of the fundus.
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The nurse is evaluating the effectiveness of lispro and glargine insulins being administered to the 2-year-old with type 1 DM. Which findings on the serum laboratory report indicate that treatment is effective?
- A. Blood glucose
- B. Hgb A1c
- C. Creatinine
- D. WBCs
Correct Answer: A, B
Rationale: The treatment goal for children with type 1 DM is blood glucose levels within the normal range (60-105 mg/dL for a 2-year-old). Hgb A1c levels are indicative of the average blood glucose levels over the past 2 to 3 months; normal A1c is 3.9% to 7.7%. Although the other laboratory values are normal, these do not indicate the effectiveness of insulin therapy.
A nurse working a surgical unit, notices a patient is experiencing SOB, calf pain, and warmth over the posterior calf. All of these may indicate which of the following medical conditions?
- A. Patient may have a DVT.
- B. Patient may be exhibiting signs of dermatitis.
- C. Patient may be in the late phases of CHF.
- D. Patient may be experiencing anxiety after surgery.
Correct Answer: A
Rationale: All of these factors (SOB, calf pain, and warmth) indicate a deep vein thrombosis (DVT), which can be a postoperative complication.
The client is started on citalopram for treatment of depression. Which information is most important for the nurse to include when teaching the client?
- A. Activity levels should be increased to include a daily exercise routine.
- B. If sexual side effects become unbearable, consult your health care provider.
- C. Taking St. John's wort with your citalopram can enhance its effectiveness.
- D. Take your blood pressure every morning and report Ascertain any significant changes.
Correct Answer: B
Rationale: Sexual dysfunction is a common side effect associated with the use of SSRIs; the client taking citalopram (Celexa), an SSRI, should consult the HCP if having unbearable sexual side effects.
Signs of impaired breathing in infants and children include all of the following except:
- A. nasal flaring.
- B. grunting.
- C. seesaw breathing.
- D. quivering lips.
Correct Answer: D
Rationale: Lip quivering is a distracter. Signs of impaired breathing in infants and children include all the other options.
The nurse is assessing the newborn's respirations. Which of these findings would indicate a need for follow-up and further intervention?
- A. irregular respirations
- B. abdominal respirations
- C. shallow respirations
- D. 70 breaths per minute
Correct Answer: D
Rationale: The respirations in a newborn are usually irregular, abdominal, and shallow. However, the ideal respiratory rate in a newborn is 30-60 breaths per minute. A respiratory rate of 70 breaths per minute indicates tachypnea and may require intervention. The other answer choices do not necessarily indicate the need for follow-up.