Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is providing discharge teaching to a client who is 3 days postoperative following a cesarean birth. Which of the following client statements indicates to the nurse that further teaching is needed??
A. "I am likely to have a fever during the first week I am home."
Having a fever during the first week at home is not a normal or expected finding and may indicate an infection, requiring further assessment.
B. "I will call my provider if I have discharge from my incision."
Contacting the provider for incisional discharge is a proper response.
C. "I should not have unrelieved pain in my abdomen."
Not having unrelieved pain in the abdomen is an appropriate expectation.
D. "I will resume taking my prenatal vitamins."
Resuming prenatal vitamins is a normal postoperative recommendation.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Maternal Newborn Proctored Exam 3 Reno 2 2020. Take the full exam now
Full Explanation
A. Having a fever during the first week at home is not a normal or expected finding and may indicate an infection, requiring further assessment.
B. Contacting the provider for incisional discharge is a proper response.
C. Not having unrelieved pain in the abdomen is an appropriate expectation.
D. Resuming prenatal vitamins is a normal postoperative recommendation.
Similar Questions
A nurse is caring for a client who reports unrelieved episiotomy pain 8 hr following a vaginal birth. Which of the following actions should the nurse take?
A. Place a hot pack to the perineum.
A hot pack to the perineum can be offered after 24 hours, but not before, as heat can increase bleeding.
B. Offer a warm sitz bath.
A warm sitz bath can be offered after 24 hours, but not before, as heat can increase bleeding and infection risk.
C. Apply an ice pack to the affected area.
The nurse should also apply an ice pack to the perineum for 20 minutes every 4 hours to reduce swelling and inflammation.
D. Provide a squeeze bottle of antiseptic solution.
Providing a squeeze bottle of antiseptic solution is more related to perineal hygiene rather than pain relief.
Full Explanation
A. A hot pack to the perineum can be offered after 24 hours, but not before, as heat can increase bleeding.
B. A warm sitz bath can be offered after 24 hours, but not before, as heat can increase bleeding and infection risk.
C. The nurse should also apply an ice pack to the perineum for 20 minutes every 4 hours to reduce swelling and inflammation.
D. Providing a squeeze bottle of antiseptic solution is more related to perineal hygiene rather than pain relief.
A nurse is preparing to administer antibiotic X over 20 min. Available is antibiotic X in 50 mL of 0.9% sodium chloride (NSS). The drop factor of the manual IV tubing is 20 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min?
(Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Full Explanation
To calculate the infusion rate for antibiotic X, the nurse needs to use the formula: gtt/min = (Volume x Drop factor) / Time
Plugging in the values from the question, we get:
gtt/min = (50 mL x 20 gtt/mL) / 20 min Simplifying, we get:
gtt/min = 1000 gtt / 20 min Dividing, we get:
gtt/min = 50 gtt/min
Therefore, the nurse should set the manual IV infusion to deliver 50 gtt/min.
A nurse on the labor and delivery unit is caring for a newborn immediately following birth. Which of the following actions by the nurse reduces evaporative heat loss by the newborn?
A. Drying the newborn's skin thoroughly
Drying the newborn's skin thoroughly helps reduce evaporative heat loss by removing wetness and promoting warmth.
B. Preventing air drafts
Preventing air drafts is important to reduce convective heat loss.
C. Placing the newborn on a warm surface
Placing the newborn on a warm surface helps prevent conductive heat loss.
D. Maintaining ambient room temperature at 24° C (75" F)
Maintaining ambient room temperature is important but does not directly address evaporative heat loss.
Full Explanation
A. Drying the newborn's skin thoroughly helps reduce evaporative heat loss by removing wetness and promoting warmth.
B. Preventing air drafts is important to reduce convective heat loss.
C. Placing the newborn on a warm surface helps prevent conductive heat loss.
D. Maintaining ambient room temperature is important but does not directly address evaporative heat loss.