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Questions 158

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Extract:


Question 1 of 5

While the RN is assessing a mother's perineum on her 2nd postpartum day after having a vaginal delivery, the RN notes a large ecchymotic area located to the left of the mother's perineum. Which one of the following interventions should the RN initiate at this time?

Correct Answer: C

Rationale: Warm sitz baths increase circulation, promote healing, and reduce edema in a traumatized perineum, making it appropriate for an ecchymotic area.

Question 2 of 5

The nurse is teaching circumcision care to the mother of a newborn. Which statement indicates that the mother needs further teaching?

Correct Answer: C

Rationale: Using a heat lamp is incorrect and could cause burns or delay healing. Petroleum gauze, cleaning, and monitoring for infection are appropriate circumcision care practices.

Question 3 of 5

A female client has been hospitalized for several months following major abdominal surgery for a ruptured colon. A colostomy was created, and the large abdominal wound was left open and allowed to heal through granulation. She is receiving gentamicin IV for treatment of wound infection. Knowing this drug is ototoxic, the nurse would implement which of the following measures?

Correct Answer: A

Rationale: The first nursing measure is to instruct the client in which drug side effects to report. Discontinuing the drug is not an independent nursing intervention and may compromise client care. Audiometric testing will detect hearing loss, but it does not indicate a potential cause. Equalizing middle ear pressure will not prevent hearing loss.

Question 4 of 5

Which behaviors are expected to be observed in the 18-month old?

Question Image

Correct Answer: B, C, E

Rationale: At 18 months, children remove clothes (
B), point to body parts (
C), and kick balls (E). Vocabulary is ~20-50 words (
A), and questioning (
D) emerges later (~2-3 years).

Question 5 of 5

The nurse is teaching a client with a history of hypertension about medication adherence. The nurse should tell the client to:

Correct Answer: A

Rationale: Adherence to antihypertensives is critical in hypertension to maintain blood pressure control and prevent complications.

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