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Questions 158

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NCLEX RN Nursing Exam Questions

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Question 1 of 5

The nurse is caring for a client with a diagnosis of postpartum endometritis. Which vital sign change is most characteristic?

Correct Answer: A

Rationale: Fever is the most characteristic vital sign change in postpartum endometritis reflecting the underlying uterine infection. Tachycardia and hypotension occur only in severe cases.

Question 2 of 5

A client with a history of ulcerative colitis is admitted with complaints of bloody diarrhea. The nurse should give priority to:

Correct Answer: A

Rationale: Bloody diarrhea in ulcerative colitis can cause significant fluid and electrolyte loss, so monitoring for dehydration is the priority.

Question 3 of 5

The nurse is caring for a client with a diagnosis of postpartum endometritis. Which vital sign change is most characteristic?

Correct Answer: A

Rationale: Fever is the most characteristic vital sign change in postpartum endometritis reflecting the underlying uterine infection. Tachycardia and hypotension occur only in severe cases.

Question 4 of 5

The physician has ordered intravenous fluid with potassium for a client admitted with gastroenteritis and dehydration. Before adding potassium to the intravenous fluid, the nurse should:

Correct Answer: A

Rationale: Potassium supplementation requires adequate renal function to prevent hyperkalemia. Assessing urinary output ensures the kidneys are functioning before adding potassium.

Question 5 of 5

Which of the following findings would be abnormal in a postpartal woman?

Correct Answer: D

Rationale: Frequently the mother experiences a shaking chill immediately after delivery, which is related to a nervous response or to vasomotor changes. If not followed by a fever, it is clinically innocuous. The pulse rate during the immediate postpartal period may be low but presents no cause for alarm. The body attempts to adapt to the decreased pressures intra-abdominally as well as from the reduction of blood flow to the vascular bed. Urinary output increases during the early postpartal period (12-24 hours) owing to diuresis. The kidneys must eliminate an estimated 2000-3000 mL of extracellular fluid associated with a normal pregnancy. A temperature of 100.4°F (38°
C) may occur after delivery as a result of exertion and dehydration of labor. However, any temperature greater than 100.4°F needs further investigation to identify any infectious process.

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