While caring for the client during the first hour after delivery, the nurse determines that the uterus is boggy and there is vaginal bleeding. What should be the nurse’s first action?
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Solution
Massage the fundus
Option B: The nurse’s first action should be to massage the fundus until it is firm as uterine atony is the primary cause of bleeding in the first hour after delivery.
The nurse is caring for a 20 lbs (9 kg) 6 month-old with a 3-day history of diarrhea, occasional vomiting and fever. Peripheral intravenous therapy has been initiated, with 5% dextrose in 0.33% normal saline with 20 mEq of potassium per liter infusing at 35 ml/hr. Which finding should be reported to the healthcare provider immediately?
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Solution
No measurable voiding in 4 hours
Option D: The concern is possible hyperkalemia, which could occur with continued potassium administration and a decrease in urinary output since potassium is excreted via the kidneys.
Following a diagnosis of acute glomerulonephritis (AGN) in their 6-year-old child, the parent’s remark: “We just don’t know how he caught the disease!” The nurse’s response is based on an understanding that
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Solution
It is not “caught” but is a response to a previous B-hemolytic strep infection
Option D: AGN is generally accepted as an immune-complex disease in relation to an antecedent streptococcal infection of 4 to 6 weeks prior and is considered as a noninfectious renal disease.
A client is scheduled for an Intravenous Pyelogram (IVP). In order to prepare the client for this test, the nurse would:
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Solution
Administer a laxative to the client the evening before the examination
Option C: Bowel prep is important because it will allow greater visualization of the bladder and ureters.
A 3-year-old had a hip spica cast applied 2 hours ago. In order to facilitate drying, the nurse should
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Solution
Expose the cast to air and turn the child frequently
Option A: The child should be turned every 2 hours, with surface exposed to the air.
The nurse is caring for a woman 2 hours after a vaginal delivery. Documentation indicates that the membranes were ruptured for 36 hours prior to delivery. What are the priority nursing diagnoses at this time?
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Solution
Risk for infection
Option D: Membranes ruptured over 24 hours prior to birth greatly increases the risk of infection to both mother and the newborn.
A 19-year-old client is paralyzed in a car accident. Which statement used by the client would indicate to the nurse that the client was using the mechanism of “suppression”?
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Solution
“I don”t remember anything about what happened to me.”
Option A: Suppression is willfully putting an unacceptable thought or feeling out of one’s mind. A deliberate exclusion “voluntary forgetting” is generally used to protect one’s own self-esteem.
A priority goal of involuntary hospitalization of the severely mentally ill client is
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Solution
Protection from self-harm and harm to others
Option C: Involuntary hospitalization may be required for persons considered dangerous to self or others or for individuals who are considered gravely disabled.
A newborn has been diagnosed with hypothyroidism. In discussing the condition and treatment with the family, the nurse should emphasize
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Solution
Administration of thyroid hormone will prevent problems
Option B. Early identification and continued treatment with hormone replacement correct this condition.
A client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA). The nurse knows that a PTCA is the
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Solution
Procedure that compresses plaque against the wall of the diseased coronary artery to improve blood flow
Option C: PTCA is performed to improve coronary artery blood flow in a diseased artery. It is performed during a cardiac catheterization. Aorta coronary bypass Graft is the surgical procedure to repair a diseased coronary artery.