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While obtaining the vital signs on a mother who delivered a healthy newborn 2 hours ago the nurse notes that the mother's temperature is 102°F. Which is the appropriate nursing action at this time?
- A. Notify the primary health care provider.
- B. Remove the blanket from the client's bed.
- C. Document the finding and recheck the temperature in 4 hours.
- D. Administer acetaminophen and recheck the temperature in 4 hours.
Correct Answer: A
Rationale: Vital signs usually return to normal within the first hour postpartum if no complications arise. A slight elevation in the temperature may be noted if the client is experiencing dehydrating effects that can occur from labor. A temperature of 102°F indicates infection, and the primary health care provider should be notified. The remaining options are inaccurate nursing interventions for a temperature of 102°F 2 hours after delivery.
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The nurse administers an intradermal injection to a client. Proper technique has been used if the injection site demonstrates which of the following?
- A. No swelling.
- B. Tissue pallor.
- C. Evidence of a bleb.
- D. Erythema.
Correct Answer: C
Rationale: A bleb (small wheal) at the injection site indicates correct intradermal technique, as the medication is deposited just under the skin.
The nurse walks into a client's room to administer the 9:00 a.m. medications and notices that the client is in an awkward position in bed. What is the nurse's first action?
- A. Ask the client his name.
- B. Check the client's name band.
- C. Straighten the client's pillow behind his back.
- D. Give the client his medications.
Correct Answer: C
Rationale: Repositioning the client first ensures comfort and safety, addressing the immediate issue of the awkward position before administering medications.
The nurse is assessing a 55-year-old client with chronic obstructive pulmonary disease. The client weighs 200 lb and is 6 feet tall. Using the diagram shown here, the nurse should record in the health history that the client's chest is:
- A. Barrel-shaped
- B. Muscular
- C. Normal for the client's age, height, and weight
- D. Showing the effects of long-term use of bronchodilators
Correct Answer: A
Rationale: A barrel-shaped chest is characteristic of chronic obstructive pulmonary disease due to hyperinflation of the lungs, which is likely in this client. The client's weight and height suggest a normal body habitus, not a muscular chest, and bronchodilator use does not directly cause this chest shape.
A client diagnosed with chronic kidney disease (CKD) has learned about managing diet and fluid restriction between dialysis treatments. The nurse determines that the client is compliant with the therapeutic regimen when the assessment demonstrates a weight gain of no more than how many kilograms between hemodialysis treatments?
- A. 0.5 to 0.9 kg
- B. 1 to 1.5 kg
- C. 2 to 4 kg
- D. 5 to 6 kg
Correct Answer: B
Rationale: The primary health care provider will prescribe the amount of fluid that the client is allowed to gain between dialysis treatments, but usually a limit of 1 to 1.5 kg of weight gain between dialysis treatments helps prevent hypotension that tends to occur during dialysis with the removal of larger fluid loads. The nurse determines that the client is compliant with fluid restriction if this weight gain is not exceeded.
A client with a history of type 2 diabetes is prescribed metformin (Glucophage). The nurse should instruct the client to:
- A. Take the medication with meals.
- B. Avoid alcohol consumption.
- C. Take the medication at bedtime.
- D. Stop the medication if nausea occurs.
Correct Answer: A, B
Rationale: Metformin should be taken with meals to reduce gastrointestinal upset, and alcohol should be avoided to prevent lactic acidosis.