Nursing Elites

1. A postpartum client is experiencing heavy lochia and a boggy uterus. What should be the nurse's initial action?

• A. Administer a uterotonic medication
• B. Encourage the client to void
• C. Perform fundal massage
• D. Increase the client's fluid intake

Correct answer: C

Rationale: The correct initial action for a postpartum client experiencing heavy lochia and a boggy uterus is to perform fundal massage. Fundal massage helps to firm the uterus and reduce bleeding by promoting uterine contractions, which can assist in preventing postpartum hemorrhage. Administering uterotonic medication may be necessary in some cases but should not be the initial action. Encouraging the client to void and increasing fluid intake can be important interventions but are not the priority in this situation where immediate uterine firmness is needed to control bleeding.

2. Which of the following are classical clinical manifestations that a patient with diabetes mellitus will exhibit EXCEPT?

• A. Polyuria
• B. Polydipsia
• C. Diabetic Ketoacidosis
• D. Weight loss

Correct answer: C

Rationale: The classical clinical manifestations of diabetes mellitus include polyuria (increased urination), polydipsia (excessive thirst), and weight loss. Diabetic ketoacidosis is not a classical manifestation but rather a serious complication that can occur in individuals with uncontrolled diabetes.

3. Based on the complaints provided by Madam KK, is the child exhibiting danger signs?

• A. Yes
• B. No
• C. I don't know
• D. Yes

Correct answer: A

Rationale: Yes, the child is displaying danger signs with symptoms such as fever and rapid breathing, indicating a potential serious health issue that requires immediate attention. The correct answer is 'Yes' because the symptoms described in Madam KK's complaints align with danger signs that suggest a severe health problem. Choices B and C are incorrect because the symptoms mentioned clearly indicate the presence of danger signs. Choice D is a duplicate of choice A and does not provide a valid alternative.

4. Which of the following is an indication of lower respiratory infection?

• A. Cough
• B. Fever
• C. Inability to lie supine
• D. Shortness of breath

Correct answer: C

Rationale: Inability to lie supine is a significant indication of lower respiratory infection. This symptom often occurs due to breathing difficulties and discomfort experienced by individuals with lower respiratory infections, such as pneumonia or bronchitis. It can be caused by lung inflammation, consolidation, or fluid buildup in the lungs, making lying flat uncomfortable or difficult. Monitoring a patient's ability to lie flat can provide valuable information about the severity and progression of a lower respiratory infection.

5. A 4-year-old boy ingested an unknown quantity of drain cleaner. He is alert, has a patent airway, and has adequate breathing. You should:

• A. administer 1 g/kg of activated charcoal.
• B. give 15 mL of ipecac and contact medical control.
• C. contact poison control and give him oxygen.
• D. give oxygen and perform a head-to-toe exam.

Correct answer: C

Rationale: When a child ingests a harmful substance like drain cleaner and remains alert with a patent airway and adequate breathing, the initial steps involve contacting poison control to guide further management. In this scenario, providing oxygen to support respiratory function is essential until definitive care is established. Activated charcoal and ipecac are not recommended in the management of ingested caustic substances like drain cleaner. Performing a head-to-toe exam can wait until the child's immediate respiratory needs are addressed and the poison control center has provided guidance on further management.

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