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A client who had an esophageal hernia repair 4 hours ago has a pulse rate of 90 bpm, respiration rate of 16/minute, blood pressure of 130/80 mm Hg, pulse oximeter of 91, and a temperature of 100.4°F (38°C). What should the nurse do first?
- A. Obtain a culture of the incision.
- B. Notify the surgeon to obtain an antibiotic order.
- C. Adjust the client to a sitting position to take deep breaths.
- D. Administer an antipyretic medication.
Correct Answer: C
Rationale: A pulse oximetry of 91 indicates mild hypoxemia. Adjusting to a sitting position and encouraging deep breaths improves oxygenation, addressing the most immediate concern.
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The nurse has attended a staff developmental conference on pediatric pain management. Which of the following statements by the nurse would indicate a correct understanding of the teaching?
- A. Patient-controlled analgesia (PCA) can be used as early as age 7.
- B. Lidocaine-adrenaline-tetracaine (LAT) can provide local anesthesia 2 hours after it is applied.
- C. Transdermal fentanyl patch can provide acute pain relief.
- D. Intramuscular delivery of pain medication is preferred for children.
Correct Answer: A
Rationale: PCA can be used in children as young as 7 if they understand the concept. LAT works within 30-60 minutes, fentanyl patches are for chronic pain, and IM injections are avoided in children due to pain and variability.
Which of the following conditions can place a client at risk for acute respiratory distress syndrome (ARDS)?
- A. Septic shock.
- B. Chronic obstructive pulmonary disease.
- C. Asthma.
- D. Heart failure.
Correct Answer: A
Rationale: Septic shock is a major ARDS risk factor due to systemic inflammation and lung injury. COPD, asthma, and heart failure are not primary ARDS triggers.
The nurse assesses the client's stoma during the initial postoperative period. Which of the following observations should be reported immediately to the physician?
- A. The stoma is slightly edematous.
- B. The stoma is dark red to purple.
- C. The stoma oozes a small amount of blood.
- D. The stoma does not expel stool.
Correct Answer: B
Rationale: A dark red to purple stoma indicates inadequate blood supply, which is a medical emergency requiring immediate reporting to the physician. Slight edema is expected post-surgery, a small amount of blood oozing is normal, and lack of stool expulsion in the initial period may not be immediately concerning unless other symptoms are present. CN: Physiological adaptation; CL: Analyze
The right hand of a client with multiple sclerosis trembles severely whenever she attempts a purposeful act, such as picking up her coffee cup or buttoning her dress. Which is the best legal documentation in nurses' notes of the chart for this client assessment?
- A. "Has an intention tremor of the right hand."
- B. "Right-hand tremor worsens with purposeful acts."
- C. "Needs assistance with dressing and eating due to severe trembling and clumsiness."
- D. "Slight shaking of right hand increases to severe tremor when client tries to button her clothes or drink from a cup."
Correct Answer: D
Rationale: The most detailed and accurate documentation is: "Slight shaking of right hand increases to severe tremor when client tries to button her clothes or drink from a cup," as it describes the intention tremor specifically and legally.
The nurse observes that a client's upper arm tremors disappear as he unbuttons his shirt. Which statement best guides the nurse's analysis of this observation about the client's tremors?
- A. The tremors are probably psychological and can be controlled at will.
- B. The tremors sometimes disappear with purposeful and voluntary movements.
- C. The tremors disappear when the client's attention is diverted by some activity.
- D. There is no explanation for the observation; it is probably a chance occurrence.
Correct Answer: B
Rationale: In Parkinson's disease, resting tremors often decrease or disappear during purposeful movements, such as unbuttoning a shirt. This is a characteristic feature, not psychological, distraction-related, or random.