Nokea
A client had abdominal surgery this morning. The nurse notices that there is a small amount of bloody drainage on his surgical dressing. The nurse would document this as what type of drainage?
- A. Serosanguinous
- B. Purulent
- C. Sanguinous
- D. Catarrhal
Correct Answer: C
Rationale: Drainage from a surgical incision is initially sanguinous, proceeding to serosanguinous, and then to serous.
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The nurse is formulating a plan of care for a client with a goiter. The priority nursing diagnosis for the client with a goiter is:
- A. Body image disturbance related to enlargement of the neck
- B. Activity intolerance related to fatigue
- C. Nutrition imbalance, less than body requirements, related to increased metabolism
- D. Risk for ineffective airway clearance related to pressure of goiter on the trachea
Correct Answer: D
Rationale: A large goiter can compress the trachea, posing a risk for ineffective airway clearance, which is a priority due to its potential to impair breathing.
The mother of a six-year-old with autistic disorder tells the nurse that her son has been much more difficult to care for since the birth of his sister. The best explanation for changes in the child's behavior is:
- A. The child did not want a sibling.
- B. The child was not adequately prepared for the baby's arrival.
- C. The child's daily routine has been upset by the birth of his sister.
- D. The child is just trying to get the parent's attention.
Correct Answer: C
Rationale: Children with autism often rely on structured routines, and disruptions, such as a new sibling, can lead to behavioral changes due to difficulty adapting to change.
The client with chronic obstructive pulmonary disease (COPD) is prescribed ipratropium (Atrovent). The nurse should teach the client to:
- A. Take the medication with meals.
- B. Report blurred vision immediately.
- C. Use the inhaler every 2 hours as needed.
- D. Avoid drinking water after use.
Correct Answer: B
Rationale: Ipratropium, an anticholinergic bronchodilator, can cause blurred vision, a side effect requiring immediate reporting. It is not taken with meals, is used every 6–8 hours, and water restriction is unnecessary.
The predominant purpose of the first Apgar scoring of a newborn is to:
- A. Determine gross abnormal motor function
- B. Obtain a baseline for comparison with the infant's future adaptation to the environment
- C. Evaluate the infant's vital functions
- D. Determine the extent of congenital malformations
Correct Answer: C
Rationale: Apgar scores are not related to the infant's care, but to the infant's physical condition. Apgar scores assess the current physical condition of the infant and are not related to future environmental adaptation. The purpose of the Apgar system is to evaluate the physical condition of the newborn at birth and to determine if there is an immediate need for resuscitation. Congenital malformations are not one of the areas assessed with Apgar scores.
A family is experiencing changes in their lifestyle in many ways. The invalid grandmother has moved in with them. The couple have a 2-year-old son by their marriage, and the wife has two children by her previous marriage. The older children are in high school. In applying systems theory to this family, it is important for the nurse to remember which of the following principles?
- A. The parts of a system are only minimally related.
- B. Dysfunction in one part affects every other part.
- C. A family system has no boundaries.
- D. Healthy families are enmeshed.
Correct Answer: B
Rationale: Any change in any part of the system affects all other parts.