Nokea
A client who had a bowel resection 5 days ago says, 'I felt like I split open when I coughed.' The nurse finds the incision edges separated and bowel protruding through the wound. Which of the following actions are appropriate? Select all that apply.
- A. Administer 1 oral tablet of oxycodone prescribed PRN for pain
- B. Collect a full set of vital signs
- C. Cover the viscera with sterile dressings saturated in normal saline solution
- D. Notify the health care provider immediately
- E. Place the client in the low Fowler position with knees slightly flexed
Correct Answer: B,C,D,E
Rationale: Vital signs, sterile saline dressings, provider notification, and low Fowler with flexed knees manage dehiscence and evisceration. Oxycodone is inappropriate during this emergency.
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A 2-year-old child seen in the emergency department is dehydrated and malnourished. The child’s parent reports that the child has had diarrhea for the past 2 weeks. Which observation is of most concern to the nurse?
- A. The parent cannot stay at the hospital due to potential job loss if late for work
- B. The parent does not seem to be concerned about the child’s condition
- C. The parent is single
- D. The parent left a 3-year-old and a 5-year-old in the care of a 9-year-old
Correct Answer: D
Rationale: Leaving young children in the care of a 9-year-old poses significant safety risks, indicating neglect and requiring immediate intervention. Job constraints, lack of concern, and single status are concerning but less immediately dangerous.
The nurse is talking with a postpartum client about resuming sexual activity after childbirth. The client had an uncomplicated vaginal delivery 2 weeks ago. Which statement by the client requires follow-up?
- A. I do not need to use condoms to prevent pregnancy until my menses returns
- B. "I should avoid resuming sexual intercourse until my vaginal bleeding has stopped."
- C. I should expect to experience vaginal dryness and can use water-soluble lubricants
- D. I will try to feed my baby before my partner and I engage in sexual activity
Correct Answer: A
Rationale: Ovulation can occur before menses returns, so condoms are needed to prevent pregnancy. Vaginal dryness is common, and feeding before sex reduces interruptions, both correct.
The nurse in the long-term care facility discovers a client with dementia wandering in the hallway during the night. Which of the following statements would be most appropriate for the nurse to make?
- A. What are you doing in the hallway? It is not time to wake up yet
- B. You should stop walking in the hallway at night because you might fall
- C. You are in the long-term care facility. Let us go back to your room together
- D. Ask a staff member to accompany you the next time you wish to leave your room
Correct Answer: C
Rationale: Orienting the client and gently redirecting them to their room is calming and safe. Questioning, warning, or instructing may confuse or agitate a client with dementia.
Laboratory reference ranges
Hematocrit
Male: 42%-52%
(0.42-0.52)
Female: 37%-47%
(0.37-0.47)
Hemoglobin
Male: 14-18 g/dL
(140-180 g/L)
Female: 12-16 g/dL
(120-160 g/L)
The nurse is reviewing the chart of a client who has a traumatic below-the-knee amputation. Which client should the nurse see first?
- A. Female client who had an arthroscopic rotator cuff repair with sling immobilization and reports moderate swelling and tingling of the hand and fingers
- B. Female client who has a new cast and reports stinging of the hand and fingers and inability to move the toes
- C. Male client who has two new prosthetic legs applied after traumatic below-the-knee amputation and reports crushing pain in the amputated areas
- D. Male client who has a hematocrit of 37% (0.37) and hemoglobin of 12.5 g/dL (125 g/L) and is prescribed enoxaparin 1 day after a total hip arthroplasty
Correct Answer: A
Rationale: Stinging and inability to move toes in a new cast suggest compartment syndrome, a surgical emergency. Phantom limb pain and normal hematocrit/enoxaparin are less urgent.
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
Correct Answer: A
Rationale: Raising the head of the bed improves breathing, and slowing the IV prevents fluid overload exacerbation in heart failure, addressing immediate distress.