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Questions 164

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Extract:


Question 1 of 5

A nurse is caring for a client who had a vaginal birth 2 hours ago. The nurse notes that the client's perineal pad is saturated with blood 20 minutes after placing a new pad. The client's fundus is boggy, palpable above the level of the umbilicus, and deviated to the right. Which intervention should the nurse perform first?

Correct Answer: C

Rationale: A boggy, deviated fundus and heavy bleeding suggest uterine atony and possible bladder distension preventing uterine contraction. Assisting to void relieves bladder pressure, promoting uterine involution. Oxytocin follows if bleeding persists.

Extract:

Laboratory Reference Ranges
Glucose (random)
71-200 mg/dL
(3.9-11.1 mmol/L)


Question 2 of 5

The student nurse completes a clinical rotation in the emergency department. The instructor knows the student is able to prioritize care appropriately when the student visits which client first?

Correct Answer: B

Rationale: Neck swelling and pain post-thyroidectomy suggest possible hematoma or airway compromise, a life-threatening emergency requiring immediate assessment. Other conditions, while serious, are less immediately critical.

Extract:


Question 3 of 5

A 6-month-old infant is being seen in the doctor's office. Which observation by the nurse should be brought to the physician's attention?

Correct Answer: B

Rationale: A 6-month-old should double birth weight (14 lb expected for 7 lb); 10 lb suggests poor growth, requiring evaluation. Other findings are developmentally normal.

Question 4 of 5

The nurse is preparing to administer ear drops to an adult client. It would require follow-up if the nurse

Correct Answer: B

Rationale: Placing the dropper into the ear canal risks injury and contamination. Ear drops should be instilled by holding the dropper above the canal. Other actions are correct: room-temperature drops prevent discomfort, pulling the pinna straightens the canal, and a cotton ball retains the medication.

Question 5 of 5

The nurse is reviewing new medication prescriptions for a client with pneumonia and chronic kidney disease. The nurse should clarify the prescription for

Correct Answer: B

Rationale: Levofloxacin is primarily excreted by the kidneys, and its use in clients with chronic kidney disease may require dose adjustments or alternative antibiotics to prevent toxicity due to impaired clearance.

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