Prior to a caesarean delivery, the client is treated for abruptio placenta. The nurse cares for the client during the postpartum period. Which symptom is suggestive of disseminated intravascular coagulation (DIC)?
The client's vital signs are: BP 90/58, temperature 101.0°F (38.3°C), pulse 112/min, respirations 18/min.
The client’s laboratory results are Hgb 13 g/dL, HCT 40% (0.40 volumn fraction), WBC 7,000/ mm3 (7x109/L).
The client is nauseated, lethargic, and has vomited three times.
There is oozing blood from the venipuncture site and abdominal incision.
The 4-week-old infant with symptoms of pyloric stenosis is brought to the outpatient clinic by the parent. Which statement does the nurse expect the parent to make about the infant's symptoms?
"My infant's bowel movements have turned black and sticky."
"I really have to encourage my infant to suck the bottle."
"My infant is fussy and seems hungry all the time."
"My infant spits up green liquid after feeding."
The health care provider(HCP) prescribes cimetidine 300 mg PO qid for an elderly client. The nurse instructs the client about the medication. Which statement, if made by the client, indicates further teaching is needed?
"I'll take this pill with meals and before bed."
"I may experience mild diarrhea for a while."
"My stools may change color while I'm on this medication."
"I should call my HCP if I get an acne-like rash."
The teenager comes to the clinic reporting fatigue, a sore throat, and flu-like symptoms for the previous 2 weeks. Physical exam reveals enlarged lymph nodes and temperature of 100.3°F (37.9°C). Which statement by the nurse is best?
"Cover your mouth and nose when you sneeze or cough."
"Eat in a separate room away from your family."
"Don't share your drinking glass or silverware with anybody."
"Stay in your room until all of your symptoms are gone."
Which strategy is most therapeutic as the nurse tries to analyze a bulimic client's eating habits and the circumstances that precipitate the client's eating problems?
Observe family communication patterns at a "monitored mealtime."
Distract the client at mealtime.
Assign the client a food/thought/feelings/actions journal.
Assign the client to write a "lifeline" in relation to eating behaviors.
The 20-year-old primipara attends a class for women who plan to breast feed. To prepare for breast feeding, the nurse should encourage the women to perform which implementation?
Apply moisturizer to the breasts every day after bathing.
Nurse the infant every 4 to 5 hours after delivery.
Wash breasts with water only.
Massage the breasts to increase circulation twice daily.
The adult client with newly diagnosed type 1 diabetes is being seen by the home health nurse. The health care provider placed the client on an 1,800-calorie ADA diet, ordered the client to self-administer 15 units of isophane each day before breakfast, and check the blood glucose qid. When the nurse visits the client at 17:00, the nurse discovers that the client has not eaten since noon and has just returned from jogging. The client's vital signs are: BP 110/80, pulse 120/min, respirations 18/min, and temperature 98.2°F (36.8°C). The nurse anticipates the client’s blood glucose to be which value?
250 mg/dL (13.88 mmol/L).
160 mg/dL (8.88 mmol/L).
90 mg/dL (5 mmol/L).
50 mg/dL (2.78 mmol/L).
The parent of the 8-month-old infant prepares to take the child home after treatment for bacterial meningitis. The parent confides to the nurse of being afraid that the child will have brain damage as a result of the illness. Which statement is the best response by the nurse?
"Trust your health care provider. They are excellent and will know what to look for."
"There is a 20% incidence of residual brain damage after this type of illness, but the odds are in your favor."
"It is an unlikely possibility, but if your child doesn't develop normally, your health care provider will help you with any problems."
"You feel guilty about your child's illness, and that's understandable. You will feel better after you get home."
The nurse cares for the child diagnosed with a fractured right femur. The child is in balanced suspension traction with a Thomas splint and Pearson attachment. When the nurse checks the client, the nurse finds the weights on the floor, and the child’s feet touching the foot of the bed. Which action by the nurse is most appropriate?
Release the traction weights and reposition the child in bed.
Pull on the traction weights while two nurse's aides pull the child up in bed.
Steady the traction and ask the child to bend the left leg and push up in bed.
Assess the child's right leg for proper position and alignment.
The nurse makes rounds on the postpartum unit. The nurse notes that a client's uterus is relaxed. The nurse should take which of the following actions?
Put the infant to the woman's breast.
Check the woman's pulse and respirations.
Encourage the woman to drink warm oral fluids.
Continue to monitor the firmness of the uterus.