Nokea
A cooling blanket is ordered for an adult client who has a temperature of 106°F. What nursing action is essential because the client has a cooling blanket?
- A. Keep a padded tongue blade at the bedside.
- B. Turn every two hours.
- C. Apply ice to the groin area.
- D. Cover with a sheet and blanket.
Correct Answer: B
Rationale: Turning every two hours prevents skin breakdown from prolonged cooling blanket contact. Tongue blades, ice, or heavy coverings are inappropriate.
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Which of the following assessment findings would indicate to the nurse the need for more sedation in a client who is withdrawing from alcohol dependence?
- A. Steadily increasing vital signs.
- B. Mild tremors and irritability.
- C. Decreased respirations and disorientation.
- D. Stomach distress and inability to sleep.
Correct Answer: A
Rationale: Steadily increasing vital signs (e.g., heart rate, blood pressure) indicate progression toward delirium tremens, a life-threatening complication of alcohol withdrawal, necessitating additional sedation. Mild tremors, decreased respirations, or gastroinTest inal symptoms are expected or contraindicate more sedation.
A client has undergone a lumbar puncture for examination of the CSF. Which of the following findings should be considered abnormal?
- A. Total protein $40 \mathrm{mg} / 100 \mathrm{~mL}$
- B. Glucose $60 \mathrm{mg} / 100 \mathrm{~mL}$
- C. Clear, colorless appearance
- D. White blood cells $100 / \mathrm{cu}$. $\mathrm{mm}$
Correct Answer: D
Rationale: Elevated white blood cells (100/cu.mm) in CSF suggest infection or inflammation, an abnormal finding. Normal protein, glucose, and clear appearance are expected.
A high school nurse observes a 14 year-old female rubbing her scalp excessively in the gym. The most appropriate course of action for the nurse to do is:
- A. Request a private evaluation of the female's scalp from her parents.
- B. Contact the female's parents about the observations.
- C. Observe the hairline and scalp for possible signs of lice.
- D. Contact the student's physician.
Correct Answer: C
Rationale: Observation of the student's hair is the next step.
In planning care for a child diagnosed with minimal change nephrotic syndrome, the nurse should understand the relationship between edema formation and
- A. Increased retention of albumin in the vascular system
- B. Decreased colloidal osmotic pressure in the capillaries
- C. Fluid shift from interstitial spaces into the vascular space
- D. Reduced tubular reabsorption of sodium and water
Correct Answer: B
Rationale: Decreased colloidal osmotic pressure in the capillaries. Loss of albumin reduces osmotic pressure, causing edema.
The nurse is caring for a client who is 2 days postoperative after a cholecystectomy. Which of the following findings would be of GREATest concern to the nurse?
- A. Temperature of 99.5°F (37.5°C).
- B. Pain at the incision site.
- C. Yellowish drainage from the incision.
- D. Urine output of 1500 mL in 24 hours.
Correct Answer: C
Rationale: Yellowish drainage from the incision suggests infection or bile leakage, a serious complication post-cholecystectomy requiring immediate evaluation. Options A, B, and D are expected or normal: slight fever is common, incision pain is typical, and urine output is adequate.