a nurse is collecting data from a client who delivered a full term newborn 16 hr ago the nurse notes excessive lochia discharge which of the following
Logo

Nursing Elites

ATI LPN

ATI PN Comprehensive Predictor 2024

1. A nurse is collecting data from a client who delivered a full-term newborn 16 hr ago. The nurse notes excessive lochia discharge. Which of the following actions should the nurse take first?

Correct answer: B

Rationale: Performing fundal massage is the priority action in this scenario. Fundal massage helps contract the uterus, which is essential in reducing excessive lochia postpartum. Administering oxytocin may be indicated later, but fundal massage should be the initial intervention to address the issue. Administering IV fluids may not directly address the cause of excessive lochia, and calling the provider should come after implementing immediate nursing interventions.

2. A nurse is performing vision testing for a client following a head injury. Which of the following findings should the nurse identify as a problem with pupil accommodation?

Correct answer: D

Rationale: Pupil accommodation problems are indicated by the lack of change in size when shifting gaze from far to near. The correct answer is D because in pupil accommodation, the pupils should constrict when shifting gaze from far to near in order to adjust for near vision. Choices A and B describe normal responses of pupil constriction when shifting gaze, which do not indicate a problem. Choice C is incorrect as it describes a normal response of pupil size change when shifting gaze from near to far.

3. A nurse in a provider's office is reinforcing teaching with a client who has a new prescription for ferrous sulfate elixir. Which of the following statements by the client should indicate to the nurse an understanding of the teaching?

Correct answer: D

Rationale: The correct answer is D because rinsing the mouth is essential to prevent staining and irritation caused by ferrous sulfate elixir. Choices A, B, and C are incorrect. Taking ferrous sulfate elixir before meals (Choice A) is not necessary. Mixing it with water (Choice B) is not recommended as it may alter the medication's effectiveness. Taking the medication once a week (Choice C) is incorrect as ferrous sulfate is usually prescribed daily or as directed by a healthcare provider.

4. A nurse is reinforcing teaching about wound care for a client who has a wound requiring irrigation. What is an important instruction?

Correct answer: B

Rationale: The correct answer is to cleanse the wound from the center outwards. This technique helps reduce the risk of contamination by pushing debris away from the wound. Option A, wearing sterile gloves, is important for infection control but not specifically related to wound irrigation. Option C, keeping the wound dry, is not suitable for wound irrigation, which often involves using solutions to clean the wound. Option D, applying an antimicrobial ointment, is not typically done during wound irrigation as the focus is on cleansing the wound.

5. A nurse is planning care for a school-age child who is 4 hr postoperative following perforated appendicitis. Which of the following actions should the nurse include in the plan of care?

Correct answer: D

Rationale: Administering analgesics on a scheduled basis for the first 24 hours is crucial to ensure adequate pain control in the immediate postoperative period. Choice A is incorrect because clear liquids are typically initiated gradually and advanced as tolerated but not specifically at 6 hours post-surgery. Choice B is incorrect as cromolyn nebulizer solution is not indicated for postoperative pain management in this scenario. Choice C is incorrect as applying a warm compress may not be appropriate for the operative site after appendicitis surgery and can potentially increase the risk of infection.

Similar Questions

A client is given morphine 6 mg IV push for postoperative pain. Following administration of this drug, the nurse observes the following: pulse 68, respirations 8, BP 100/68, client sleeping quietly. Which of the following nursing actions is MOST appropriate?
A nurse is reinforcing teaching about home care for conjunctivitis with the parent of a school-age child. Which of the following information should the nurse include?
What is the proper technique for administering an intramuscular (IM) injection?
What are the key components of a neurological assessment?
A nurse is reviewing the medical record of a client who has schizophrenia and is taking clozapine. Which of the following findings should the nurse identify as a contraindication to the administration of clozapine?

Access More Features

ATI LPN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI LPN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses