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A nurse at an urgent care clinic is contributing to the plan of care for a client following a near drowning while attempting to walk across a frozen pond. Which of the following interventions should the nurse recommend?
- A. Replace wet clothing with warmed blankets.
- B. Use an axillary thermometer to monitor the client's temperature.
- C. Assist the client to perform range-of-motion exercises.
- D. Administer an antihypertensive medication.
Correct Answer: A
Rationale: Replacing wet clothing with warmed blankets prevents hypothermia, a critical risk after a near-drowning incident.
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A nurse is collecting data from an older adult client. Which of the following findings should indicate to the nurse that the client has a bladder infection?
- A. Changed mental status
- B. Temperature 37.3°C (99.1°F)
- C. WBC count 9,000/mm3 (5000 to 10,000/mm3)
- D. Diminished reflexes
Correct Answer: A
Rationale: Changed mental status is a common sign of a bladder infection (UTI) in older adults, often presenting as confusion rather than typical urinary symptoms.
A nurse is contributing to the plan of care for a client who has AIDS and has malnutrition. Which of the following actions should the nurse include in the plan of care?
- A. Encourage three large meals daily.
- B. Season foods with spices.
- C. Provide a high-calorie diet.
- D. Administer an antiemetic after each meal.
Correct Answer: C
Rationale: A high-calorie diet addresses malnutrition in AIDS clients, supporting nutritional needs and immune function.
A nurse is caring for a client who is 2 days postoperative following abdominal surgery. The nurse auscultates hypoactive bowel sounds, and the client reports cramping abdominal pain. Which of the following actions should the nurse take first?
- A. Administer a glycerin suppository.
- B. Ambulate the client in the hallway.
- C. Request the client to be NPO.
- D. Offer an analgesic medication.
Correct Answer: B
Rationale: Ambulating the client first promotes bowel motility, addressing hypoactive bowel sounds and cramping, a common postoperative issue.
A nurse is assisting with the transfer of a client from a medical-surgical unit to an intensive care unit following a change in status. Which of the following information should the nurse include in the transfer documentation?
- A. Current medication prescriptions
- B. Primary health problem
- C. Number of family members who have visited
- D. Admission vital signs from 1 week ago
- E. Scheduled times for dressing changes
Correct Answer: A,B,E
Rationale: Medications, primary problem, and dressing schedules are critical for continuity of care in the ICU; family visits and old vital signs are less relevant.
A nurse is assisting in the care of a client who is postoperative following an open reduction internal fixation of the right tibia.
Nurses' Notes
Vital Signs
Diagnostic Results
Day 1:
Client brought to the emergency department (ED) following a fall that occurred while downhill skiing. Client states they fell when turning to avoid hitting another skier. Client reports feeling a severe, sudden pain of the right leg upon falling. Right leg was immobilized at the scene and the client transported to the ED.
Client states they were wearing a helmet while skiing. Client reports no headache or loss of consciousness.
Client reports pain as 10 on a scale of 0 to 10 to the right lower leg just below the knee and is unable to bear weight.
Right proximal tibia ecchymotic and swollen below the knee. Area is painful to touch. Open area noted on skin with bone visible. Right knee appears displaced. Left pedal pulses 3+, foot warm with intact movement and sensation. Right pedal pulses 1+, foot cool to palpation with minimal movement and reduced sensation.
For each finding, click to specify if the finding is consistent with acute compartment syndrome, infection, and/or fat embolism syndrome. Each finding might support more than 1 disease process.
- A. Dyspnea
- B. Increased pain at incision site
- C. Tingling sensation to right foot
- D. Swelling at incision site
Correct Answer: A (fat embolism syndrome), B (acute compartment syndrome, infection), C (acute compartment syndrome), D (acute compartment syndrome, infection)
Rationale: Dyspnea is typical of fat embolism; increased pain and swelling suggest compartment syndrome or infection; tingling indicates compartment syndrome.