NCLEX Questions, Mock NCLEX RN Exam Questions, NCLEX-RN Questions, Nurselytic

Correct Answer: D

Rationale: The length of labor has little bearing on the fourth stage of labor. The type of labor and delivery is significant. The type of episiotomy will affect the client's comfort level. However, the nurse's assessment and implementations center on prevention of hemorrhage during the fourth stage of labor. The amount of bleeding from the episiotomy or hematoma formation is of higher priority than the type of episiotomy. The amount of IV fluid to be infused is a nursing function to be attended to; however, it is lower in priority than determining if hemorrhaging is occurring. Character of the fundus would be the priority nursing assessment because changes in uterine tone may identify possible postpartum hemorrhage.

Correct Answer: A

Rationale: Atrial flutter causes rapid heart rates, which can lead to dizziness due to reduced cardiac output, so monitoring heart rate is the priority.

Correct Answer: D

Rationale: Maintaining a low-humidified environment. Avoiding furry, soft stuffed animals for play, which may increase symptoms of allergy. Avoiding showering, which irritates the dermatitis, and encouraging bathing 4 times a day in colloid bath for temporary relief. Wrapping hands in soft cotton gloves to prevent skin damage during scratching.

Correct Answer: B

Rationale: Gas-forming foods such as cabbage should be avoided.

Correct Answer: A

Rationale: Elderly clients with Alzheimer's dementia are at highest risk for abuse due to cognitive impairment, dependency, and potential caregiver stress. The other conditions pose less risk.