Nokea
A client post-inguinal herniorrhaphy reports scrotal swelling 24 hours after surgery. Which action should the nurse take first?
- A. Apply a warm compress to the scrotum.
- B. Notify the surgeon.
- C. Elevate the scrotum and apply ice.
- D. Administer a diuretic as ordered.
Correct Answer: C
Rationale: Elevating the scrotum and applying ice is the first action to reduce scrotal swelling post-inguinal herniorrhaphy, a common postoperative finding. Warm compresses may worsen swelling, notification is needed if swelling persists, and diuretics are not indicated. CN: Physiological adaptation; CL: Synthesize
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A client with pneumonia has a temperature of 102.6°F (39.2°C), is diaphoretic, and has a productive cough. The nurse should include which of the following measures in the plan of care?
- A. Position changes every 4 hours.
- B. Nasotracheal suctioning to clear secretions.
- C. Frequent linen changes.
- D. Frequent offering of a bedpan.
Correct Answer: C
Rationale: Diaphoresis from fever causes damp linens, which can lead to discomfort and skin breakdown; frequent linen changes are needed. Position changes aid lung expansion but are less urgent. Suctioning is invasive and not routinely required. Bedpan use depends on mobility, not fever.
The nurse is evaluating the discharge teaching for a client who has an ileal conduit. Which of the following statements indicates that the client has correctly understood the teaching? Select all that apply.
- A. If I limit my fluid intake, I will not have to empty my ostomy pouch as often.
- B. I can place an aspirin tablet in my pouch to decrease odor.
- C. I can usually keep my ostomy pouch on for 3 to 7 days before changing it.
- D. I must use a skin barrier to protect my skin from urine.
- E. I should supply my ostomy pouch of urine when it is full.
Correct Answer: C,D
Rationale: Keeping the pouch on for 3-7 days and using a skin barrier are correct practices. Limiting fluids increases infection risk, aspirin is unsafe, and the last option is unclear but likely a typo for emptying when full, which is correct but not listed as such.
A client with renal calculi reports sudden cessation of pain. The nurse should:
- A. Strain all urine.
- B. Administer analgesics.
- C. Check vital signs.
- D. Encourage bed rest.
Correct Answer: A
Rationale: Sudden pain cessation may indicate stone passage; straining urine confirms this.
The nurse receives emergency laboratory results for a client with chest pain and immediately informs the physician. An increased myoglobin level suggests which of the following?
- A. Cancer.
- B. Hypertension.
- C. Liver disease.
- D. Myocardial damage.
Correct Answer: D
Rationale: Elevated myoglobin indicates myocardial damage, as it is released from injured cardiac muscle, supporting a diagnosis of MI.
The nurse is planning care for a client with a femoral fracture who is in balanced suspension traction. Which of the following would the nurse be least likely to include in the plan of care?
- A. Use of a fracture bedpan.
- B. Checks for redness over the ischial tuberosity.
- C. Elevation of the head of bed no more than 25 degrees.
- D. Personal hygiene with a complete bed bath.
Correct Answer: C
Rationale: Elevating the head of the bed beyond 25 degrees can disrupt traction alignment, making it least appropriate.