Test Prep National Council Licensure Examination - NCLEX-RN NCLEX-RN Dumps in PDF

Free Test Prep NCLEX-RN Real Questions (page: 37)

Which of the following findings would be abnormal in a postpartal woman?

  1. Chills shortly after delivery
  2. Pulse rate of 60 bpm in morning on first postdelivery day
  3. Urinary output of 3000 mL on the second day after delivery
  4. An oral temperature of 101F (38.3C) on the third day after delivery

Answer(s): D

Explanation:

(A) Frequently the mother experiences a shaking chill immediately after delivery, which is related to a nervous response or to vasomotor changes. If not followed by a fever, it is clinically innocuous. (B) The pulse rate during the immediate postpartal period may be low but presents no cause for alarm. The body attempts to adapt to the decreased pressures intra-abdominally as well as from the reduction of blood flow to the vascular bed. (C) Urinary output increases during the early postpartal period (12­24 hours) owing to diuresis. The kidneys must eliminate an estimated 2000­3000 mL of extracellular fluid associated with a normal pregnancy. (D) A temperature of 100.4F (38C) may occur after delivery as a result of exertion and dehydration of labor. However, any temperature greater than 100.4F needs further investigation to identify any infectious process.



Which of the following findings would be abnormal in a postpartal woman?

  1. Chills shortly after delivery
  2. Pulse rate of 60 bpm in morning on first postdelivery day
  3. Urinary output of 3000 mL on the second day after delivery
  4. An oral temperature of 101F (38.3C) on the third day after delivery

Answer(s): D

Explanation:

(A) Frequently the mother experiences a shaking chill immediately after delivery, which is related to a nervous response or to vasomotor changes. If not followed by a fever, it is clinically innocuous. (B) The pulse rate during the immediate postpartal period may be low but presents no cause for alarm. The body attempts to adapt to the decreased pressures intra-abdominally as well as from the reduction of blood flow to the vascular bed. (C) Urinary output increases during the early postpartal period (12­24 hours) owing to diuresis. The kidneys must eliminate an estimated 2000­3000 mL of extracellular fluid associated with a normal pregnancy. (D) A temperature of 100.4F (38C) may occur after delivery as a result of exertion and dehydration of labor. However, any temperature greater than 100.4F needs further investigation to identify any infectious process.



As the nurse assesses a male adolescent with chlamydia, the nurse determines that a sign of chlamydia is:

  1. Enlarged penis
  2. Secondary lymphadenitis
  3. Epididymitis
  4. Hepatomegaly

Answer(s): C

Explanation:

(A) An enlarged penis is not a sign of chlamydia. (B) Secondary lymphadenitis is a complication of lymphogranuloma venereum. (C) Untreated chlamydial infection can spread from the urethra, causing epididymitis, which presents as a tender, scrotal swelling. (D) Hepatomegaly is not a complication.



As the nurse assesses a male adolescent with chlamydia, the nurse determines that a sign of chlamydia is:

  1. Enlarged penis
  2. Secondary lymphadenitis
  3. Epididymitis
  4. Hepatomegaly

Answer(s): C

Explanation:

(A) An enlarged penis is not a sign of chlamydia. (B) Secondary lymphadenitis is a complication of lymphogranuloma venereum. (C) Untreated chlamydial infection can spread from the urethra, causing epididymitis, which presents as a tender, scrotal swelling. (D) Hepatomegaly is not a complication.



During burn therapy, morphine is primarily administered IV for pain management because this route:

  1. Delays absorption to provide continuous pain relief
  2. Facilitates absorption because absorption from muscles is not dependable
  3. Allows for discontinuance of the medication if respiratory depression develops
  4. Avoids causing additional pain from IM injections

Answer(s): B

Explanation:

(A) Absorption would be increased, not decreased. (B) IM injections should not be used until the client is hemodynamically stable and has adequate tissue perfusion. Medications will remain in the subcutaneous tissue with the fluid that is present in the interstitial spaces in the acute phase of the thermal injury. The client will have a poor response to the medication administered, and a "dumping" of the medication can occur when the medication and fluid are shifted back into the intravascular spaces in the next phase of healing. (C) IV administration of the medication would hasten respiratory compromise, if present. (D) The desire to avoid causing the client additional pain is not a primary reason for this route of administration.



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