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Questions 164

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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.

Question 2 of 5

The nurse is reinforcing teaching for a client with atrial fibrillation who has a new prescription for warfarin. The nurse should instruct the client to avoid excess or inconsistent intake of which of the following foods? Select all that apply.

Correct Answer: C,D,E

Rationale: Broccoli, spinach, and kale are high in vitamin K, which can antagonize warfarin's anticoagulant effect. Consistent intake is key, but excess can reduce effectiveness. Red meat and bananas have minimal vitamin K and don't significantly affect warfarin.

Question 3 of 5

A client with a knee injury is scheduled for an MRI examination. The nurse explains the test to the client. Which finding in the client would make the client ineligible for this type of exam?

Correct Answer: A

Rationale: A metal plate is a contraindication for MRI due to magnetic interference, making the client ineligible.

Question 4 of 5

The nurse is assessing a 12 year-old who has hemophilia A. Which finding would the nurse anticipate?

Correct Answer: C

Rationale: Hemophilia A is characterized by an absence or deficiency of Factor VIII.

Question 5 of 5

The nurse is talking with a client with alcohol use disorder who has a new prescription for disulfiram. Which of the following information should the nurse include?

Correct Answer: C

Rationale: Disulfiram causes severe adverse reactions when alcohol is consumed, even in small amounts found in products like mouthwash. Clients must avoid all alcohol-containing products to prevent a disulfiram-alcohol reaction, which can include nausea, vomiting, and flushing.

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