Nokea
A client returns from the operating room after a right orchiectomy. For the immediate post-operative period the nursing priority would be to
- A. maintain fluid and electrolyte balance
- B. manage post-operative pain
- C. ambulate the client within 1 hour of surgery
- D. control bladder spasms
Correct Answer: B
Rationale: Due to the location of the incision, pain management is the priority. Bladder spasms are more related to prostate surgery.
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The nurse is talking with the parent of a 15-month-old client who is scheduled to receive the varicella vaccine. Which of the following statements would be appropriate for the nurse to make? Select all that apply.
- A. Your child may develop a low-grade fever after receiving the vaccine
- B. Your child can have aspirin to decrease discomfort caused by the vaccine.
- C. Your child may develop a rash at the injection site after receiving the vaccine.
- D. Your child will require a second dose of the vaccine at a subsequent visit.
- E. Your child should not receive any other vaccines at the same visit.
Correct Answer: A,C,D
Rationale: The varicella vaccine may cause a low-grade fever (A) or a rash at the injection site (C) as common side effects. A second dose (D) is required at 4-6 years for full immunity. Aspirin (B) is contraindicated in children due to Reye’s syndrome risk. Other vaccines (E) can be given concurrently, per CDC guidelines, unless contraindicated.
A young adult is admitted with a possible head injury. The car in which he was riding hit a utility pole, and the client's head hit the windshield. Baseline vital signs are BP=112/74, P=80, and R=12. The nurse checks the client an hour after admission. Which finding(s) are significant and should be reported to the charge nurse or physician immediately? Select all that apply.
- A. BP=126/68
- B. Pulse=62
- C. Respirations=8
- D. Projectile vomiting
- E. Client's skin is cool to the touch.
- F. Both pupils respond to exposure to flashlight by constricting.
Correct Answer: C,D
Rationale: Slow respirations (8) and projectile vomiting suggest increased intracranial pressure, critical in head injury, requiring immediate reporting. BP, pulse, skin, and pupil response changes are less urgent.
The nurse is caring for a client with suspected colorectal cancer. Which of the following findings would support a diagnosis of colorectal cancer? Select all that apply.
- A. Fatigue
- B. Blood in the stool
- C. Change in bowel habits
- D. Unintentional weight loss
- E. Elevated hemoglobin level
Correct Answer: A,B,C,D
Rationale: Colorectal cancer often presents with fatigue (A) due to anemia or systemic effects, blood in the stool (B) from tumor bleeding, changes in bowel habits (C) like diarrhea or constipation, and unintentional weight loss (D) from malignancy-related cachexia. Elevated hemoglobin (E) is unlikely, as anemia is more common due to chronic blood loss.
The nurse is caring for a 9-year-old client with cystic fibrosis who is scheduled to receive pancrelipase at 1200. The client states, 'I am not hungry now. I want to eat lunch in a few hours.' Which of the following actions should the nurse take?
- A. Omit the dose of medication.
- B. Administer half the dose of medication.
- C. Administer the dose of medication with a small snack
- D. Hold the dose of medication until the client is ready to eat.
Correct Answer: C
Rationale: Pancrelipase aids digestion in cystic fibrosis and should be taken with food. A small snack (C) ensures enzyme effectiveness while respecting the child’s appetite. Omitting (A) or halving (B) the dose risks malabsorption, and holding (D) delays nutrition.
During the charge nurse’s morning rounds, a client says, 'I hope you will take better care of me than the nurse I had last night.' What should be the charge nurse’s initial response?
- A. Apologize for the previous nurse’s treatment
- B. Ask the client to describe what happened last night
- C. Explain that the night nurse was probably busy
- D. Reassure the client that things will be better today
Correct Answer: B
Rationale: Asking for details (B) allows the charge nurse to understand the client’s concerns and address specific issues. Apologizing (A) assumes fault, excusing the nurse (C) dismisses the concern, and reassurance (D) lacks follow-through without investigation.