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Question 1 of 5.

The home health nurse is caring for an 85-year-old client. It would require immediate follow-up if the client is reporting

A. a painful red area on the buttocks

B. new onset of dependent edema of the feet

C. progressive loss of central vision

D. no memory of activities performed yesterday

Explanation: A painful red area on the buttocks suggests a pressure injury, requiring immediate intervention to prevent worsening. Edema, vision loss, and memory issues are concerning but less urgent.

Question 2 of 5.

The LPN is caring for all of the following women on the postpartum unit. Which situation requires further attention?

A. A woman who gave birth four hours ago has red vaginal drainage on her perineal pad.

B. The nurse palpates the uterine fundus 3 cm above the umbilicus in a woman who gave birth 12 hours ago.

C. A woman who had a 20-hour labor and gave birth 8 hours ago asks the nurse not to bring her baby in for breastfeeding during the night.

D. A woman who gave birth yesterday is sweating profusely and producing large amounts of urine.

Explanation: A fundus 3 cm above the umbilicus 12 hours postpartum suggests uterine atony or retained clots, requiring further assessment to prevent hemorrhage. Other findings are normal or less urgent.

Question 3 of 5.

An adult asks the nurse what could be causing him to have a black tongue and black stools. The following items are in the client's history. Which is most likely to be causing his symptoms?

A. He is taking bismuth subsalicylate (Pepto-Bismol) for loose stools.

B. He has been eating a lot of beets and broccoli recently.

C. He has been taking iron tablets for anemia.

D. He eats a lot of red meat.

Explanation: Bismuth subsalicylate commonly causes black tongue and stools, a harmless side effect, unlike the other options.

Question 4 of 5.

The nurse is caring for a woman admitted with heart failure. The client has an IV running at 125 mL/hr. The client calls the nurse stating she is having difficulty breathing. The nurse observes that she is short of breath and in distress. What should the nurse do initially?

A. Slow the IV and raise the head of the bed

B. Call the physician

C. Take the client's blood pressure

D. Notify the charge nurse

Explanation: Raising the head of the bed improves breathing, and slowing the IV prevents fluid overload exacerbation in heart failure, addressing immediate distress.

Question 5 of 5.

An adult is being discharged on a low-sodium, low-fat diet. Which menu, if selected by the client, indicates an understanding of the diet?

A. Hamburger with fries, apple pie, milkshake

B. Tossed salad with vinaigrette dressing, baked skinny chicken, applesauce

C. Steak, corn on the cob, fruit salad

D. Fried shrimp, coleslaw, strawberry shortcake

Explanation: Tossed salad, baked skinless chicken, and applesauce are low in sodium and fat, aligning with the prescribed diet.

Related Questions

The nurse is talking with the parents of an adolescent client who was brought to the emergency department after making superficial cuts on the arms with a razor blade. There are several cuts in various stages of healing on the client's forearms. Which of the following statements would be appropriate for the nurse to make? Select all that apply.

A nurse caring for a client with a central venous catheter (CVC) enters the client's room and notes that the CVC is dislodged and lying in the client's bed linens. The client appears cyanotic and is tachypneic and diaphoretic. Which of the following actions by the nurse are appropriate? Select all that apply.

The nurse is caring for a client who has a prescription for 25 units of NPH insulin and sliding-scale regular insulin. The client's serum glucose level is 237 mg/dL (13.2 mmol/L). How many total units of insulin should the nurse administer to the client? Record your answer using a whole number.

The nurse is reinforcing teaching about measures to prevent the transmission of hepatitis A for a group of clients at an outpatient treatment facility for substance use disorders. Which of the following information would be most important for the nurse to include?

An elderly war veteran with prostate cancer and coronary artery disease is hospitalized for urosepsis. The client becomes angry with one of the unlicensed assistive personnel (UAP) who is trying to help the client bathe. Later, the UAP expresses frustration with the client to the nurse. Which statement would be the most appropriate response?

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