Nokea
A client who had an exploratory laparotomy 3 days ago has a white blood cell (WBC) differential with a shift to the left. The nurse instructs unlicensed personnel to report which clinical manifestation?
- A. Swelling around the incision.
- B. Redness around the incision.
- C. Elevated temperature.
- D. Purulent wound drainage.
Correct Answer: C
Rationale: A left shift in the WBC differential indicates an increase in immature neutrophils, often due to infection. An elevated temperature is a key sign of infection and should be reported promptly. Swelling, redness, and purulent drainage are also concerning but may develop later.
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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.
After treatment with radioactive iodine (RAI) in the form of sodium iodide 131I, the nurse teaches the client to:
- A. Monitor for signs and symptoms of hyperthyroidism.
- B. Rest for 1 week to prevent complications of the medication.
- C. Take thyroxine replacement for the remainder of the client's life.
- D. Assess for hypertension and tachycardia resulting from altered thyroid activity.
Correct Answer: C
Rationale: RAI often destroys enough thyroid tissue to cause hypothyroidism, requiring lifelong thyroxine replacement. Monitoring for hyperthyroidism is unnecessary post-treatment, and rest or assessing for hypertension/tachycardia are not primary concerns.
Which of the following expected outcomes would be appropriate for a client with viral hepatitis? The client will:
- A. Demonstrate a decrease in fluid retention related to ascites.
- B. Verbalize the importance of reporting bleeding gums or bloody stools.
- C. Limit use of alcohol to two to three drinks per week.
- D. Restrict activity to within the home to prevent disease transmission.
Correct Answer: B
Rationale: Reporting bleeding (B) indicates awareness of complications like coagulopathy. Ascites (A) is more relevant to cirrhosis. Alcohol (C) should be avoided entirely. Restricting activity to home (D) is unnecessary for hepatitis B or C.
The nurse is suctioning a client who had a laryngectomy. What is the maximum amount of time the nurse should suction the client?
- A. 10 seconds.
- B. 15 seconds.
- C. 25 seconds.
- D. 30 seconds.
Correct Answer: B
Rationale: Suctioning for no more than 15 seconds prevents hypoxia and trauma to the airway. Longer durations risk oxygen deprivation.
A client with breast cancer has abdominal bloating and cramping with no bowel movement for 5 days. She says she usually has a bowel movement every day after her morning coffee. Bowel sounds are present in all four quadrants. She received 80 mg of doxorubicin hydrochloride (Adriamycin) 10 days ago. The nurse should contact the health care provider to request an order for which of the following?
- A. A Fleet enema to stimulate peristalsis.
- B. A soapsuds enema until clear.
- C. A small-volume tap water enema to stimulate a bowel movement; then evaluate the need for daily stool softeners.
- D. A daily stool softener for constipation and a mild opioid for abdominal discomfort.
Correct Answer: C
Rationale: A small-volume tap water enema is a gentle, effective intervention to stimulate a bowel movement, followed by evaluation for stool softeners to prevent recurrence, addressing chemotherapy-related constipation.