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Questions 158

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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

A client is to be discharged from the hospital and is to continue taking warfarin 2.5 mg po bid. Which of the following should be included in her discharge teaching concerning the warfarin therapy?

Correct Answer: C

Rationale: Warfarin must always be taken exactly as directed. Clients should be instructed never to skip or double up on their dosage. Aspirin decreases platelet aggregation, which would potentiate the effects of the coumadin. Healthcare providers need to be aware of persons on warfarin therapy prior to the initiation of any diagnostic tests and/or surgery to help prevent bleeding complications. An electric razor should be used to prevent accidental cutting, which can lead to bleeding.

Question 3 of 5

A 12-year-old girl has been diagnosed with insulin-dependent diabetes mellitus. Which of these principles would best guide her nutritional management?

Correct Answer: C

Rationale: Concentrated sweets are eliminated from diet planning. Complex carbohydrates may be taken at the time of increased activity. Food restriction is not used for diabetic control of growing children. Caloric restriction may be imposed for weight control if necessary.
Total caloric intake and proportions of basic nutrients should be consistent from day to day. Distribution of these calories should fit the activity pattern. Extra food is needed for increased activity. A balance of food, exercise, and insulin should be maintained. Because of the increased risk of atherosclerosis, the fat percentage of the total caloric intake is reduced.

Question 4 of 5

The registered nurse is making shift assignments. Which client should be assigned to the licensed practical nurse (LPN)?

Correct Answer: A

Rationale: A diabetic with a foot ulcer is stable and suitable for an LPN, who can perform wound care and monitoring. Heparin infusion (
B), tracheostomy weaning (
C), and T-tube management (
D) require RN-level skills due to complexity and risk.

Question 5 of 5

The charge nurse is making assignments for the day. After accepting the assignment to care for a client with leukemia, the nurse tells the charge nurse that her child has chickenpox. Which initial action should the charge nurse take?

Correct Answer: D

Rationale: The charge nurse should first ask if the nurse has had chickenpox or been vaccinated, as immunity prevents transmission to the immunocompromised leukemia client. If non-immune, the assignment should be changed. Asking about crusting or explaining no risk is incorrect, as varicella is contagious until lesions crust.

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