Nokea
While caring for the client during the first hour after delivery, the nurse determines that the uterus is boggy and there is vaginal bleeding. What should be the nurse's first action?
- A. Check vital signs
- B. Massage the fundus
- C. Offer a bedpan
- D. Check for perineal lacerations
Correct Answer: B
Rationale: Massage the fundus. The nurse's first action should be to massage the fundus until it is firm as uterine atony is the primary cause of bleeding in the first hour after delivery. Checking vital signs, offering a bedpan, or checking for perineal lacerations are important assessments but addressing the boggy uterus and vaginal bleeding due to uterine atony takes precedence in this situation.
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A client with asthma has low-pitched wheezes present on the final half of exhalation. One hour later the client has high-pitched wheezes extending throughout exhalation. This change in assessment indicates to the nurse that the client
- A. Has increased airway obstruction
- B. Has improved airway obstruction
- C. Needs to be suctioned
- D. Exhibits hyperventilation
Correct Answer: B
Rationale: The higher pitched a sound is, the more narrow the airway. Therefore, the obstruction has increased or worsened. With no evidence of secretions, there is no support to indicate the need for suctioning. Wheezes changing from low-pitched to high-pitched and extending throughout exhalation suggest a progression in airway constriction, indicating an increase in airway obstruction. Option B is incorrect because the change in wheezes from low to high pitch does not suggest an improvement in airway obstruction. Option C is incorrect as there is no indication of secretions requiring suctioning. Option D is incorrect as hyperventilation is not typically associated with the described change in wheezes.
The nurse provides home care instructions to the parents of a child with celiac disease. The nurse should teach the parents to include which food item in the child's diet?
- A. Rice
- B. Oatmeal
- C. Rye toast
- D. White bread
Correct Answer: A
Rationale: In celiac disease, individuals are intolerant to gluten found in wheat, barley, rye, and oats. Therefore, it is crucial to eliminate these grains from the diet. Rice, corn, or millet are safe alternatives for individuals with celiac disease. Oatmeal is generally avoided unless specifically labeled as gluten-free due to possible cross-contamination. Rye toast and white bread contain gluten and should be avoided in celiac disease. Vitamin supplements may also be necessary to address deficiencies caused by dietary restrictions.
A patient in the emergency room has a fractured left elbow and presents with an unequal radial pulse, swelling, and numbness in the left hand after waiting for 5 hours. What is the nurse's priority intervention?
- A. Place the patient in a supine position
- B. Ask the patient to rate his pain on a scale of 1 to 10.
- C. Wrap the fractured area with a snug dressing
- D. Start an IV in the other arm.
Correct Answer: D
Rationale: The correct answer is to start an IV in the other arm. In this scenario, the patient is showing signs of Acute Compartment Syndrome, a serious condition that occurs due to increased pressure within a muscle compartment, leading to decreased blood flow and potential tissue damage. Starting an IV is crucial as the patient may require emergency surgery, such as a fasciotomy, to relieve the pressure and prevent further complications. Placing the patient in a supine position, asking about pain levels, or wrapping the fractured area, though important, are not the priority interventions in this critical situation where immediate medical intervention is necessary to prevent irreversible damage or loss of limb.
Why are subdural hemorrhages more common in the elderly?
- A. Increased anticoagulant use
- B. Increased risk of falls
- C. Brain atrophy
- D. Inconsistent care giving
Correct Answer: C
Rationale: Subdural hemorrhages are more common in the elderly due to cerebral atrophy resulting from the natural aging process. This atrophy can lead to the stretching of bridging veins, making them more fragile and prone to tearing even with minor trauma. While increased anticoagulant use and a higher risk of falls are common in the elderly, brain atrophy plays a more direct role in the increased incidence of subdural hemorrhages. Inconsistent caregiving, on the other hand, is not a direct cause of subdural hemorrhages but may impact the overall management and outcome of such cases.
A client asks the nurse about including her 2 and 12-year-old sons in the care of their newborn sister. Which of the following is an appropriate initial statement by the nurse?
- A. Focus on your sons' needs during the first days at home.
- B. Tell each child what he can do to help with the baby.
- C. Suggest that your husband spend more time with the boys.
- D. Ask the children what they would like to do for the newborn.
Correct Answer: A
Rationale: It is essential for the nurse to guide the client on the initial steps in involving her 2 and 12-year-old sons in the care of their newborn sister. The most appropriate response is to 'Focus on your sons' needs during the first days at home.' In an expanded family, parents should prioritize reassuring older children that they are loved and as important as the newborn. This response acknowledges the importance of ensuring the well-being and emotional adjustment of the older siblings during the transition period. Choices B, C, and D are less appropriate as they do not directly address the emotional needs and adjustment of the older children during this significant family change.