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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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The nurse is assisting with the care of a client. For each finding, click to specify if the finding is consistent with small bowel obstruction or acute pancreatitis. Each finding may support more than 1 disease process.
- A. Pain level
- B. Social history
- C. Skin findings
- D. Lipase level
- E. WBC count
- F. Abdominal findings
Correct Answer: A (small bowel obstruction, acute pancreatitis), B (acute pancreatitis), C (neither), D (acute pancreatitis), E (small bowel obstruction, acute pancreatitis), F (small bowel obstruction)
Rationale: Pain level and abdominal findings (tenderness, high-pitched bowel sounds) support small bowel obstruction and acute pancreatitis; social history (alcohol use) and lipase support pancreatitis; WBC count supports both; skin findings (no jaundice) support neither.
A nurse is caring for a client who is 6 hr postoperative following a bowel resection. Which of the following findings is the priority for the nurse to report?
- A. The client arouses easily but quickly falls back asleep.
- B. There is 20 mL of dark red drainage from the wound drainage device over the past 4 hr.
- C. There is 60 mL of dark yellow urine from the indwelling urinary catheter over the past 4 hr.
- D. The client reports a pain level of 6 on a scale from 0 to 10 at the incision site.
Correct Answer: A
Rationale: Difficulty staying awake 6 hours post-op suggests potential respiratory depression or neurological issues, a priority to report.
A nurse is reinforcing teaching about saturated fats with a client who is at risk for cardiovascular disease. Which of the following cooking fats should the nurse recommend the client use?
- A. Canola oil
- B. Butter
- C. Vegetable shortening
- D. Lard
Correct Answer: A
Rationale: Canola oil is low in saturated fat and heart-healthy, unlike butter, shortening, or lard, reducing cardiovascular risk.
A nurse is assisting in the care of the client who is postoperative following a fasciotomy. Which of the following actions should the nurse take?
- A. Prepare to obtain a wound culture.
- B. Restrict fluid intake.
- C. Administer an analgesic
- D. Prepare to administer an antibiotic
- E. Initiate supplemental oxygen.
Correct Answer: A,C,D
Rationale: Wound culture assesses for infection, analgesics manage pain, and antibiotics treat potential infection post-fasciotomy; fluid restriction and oxygen are not indicated.
A nurse is reinforcing teaching with a 30-year-old client who is concerned about cervical cancer. Which of the following statements should the nurse make?
- A. Cervical cancer screenings should begin at age 40
- B. Plan to continue cervical cancer screenings for the rest of your life.
- C. You should get a Papanicolaou (Pap) test and human papillomavirus test every 5 years.
- D. If you are immunized against human papillomavirus, you don't need cervical cancer screenings.
Correct Answer: C
Rationale: For a 30-year-old, Pap and HPV testing every 5 years is recommended per current guidelines, making this the correct statement.