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A nurse in an acute care facility is caring for a client who is postop following abdominal surgery. Which of the following behaviors should the nurse identify as increasing the client's risk for constipation?
- A. Regular fluid intake
- B. Urge suppression
- C. Increased physical activity
- D. Adequate dietary fiber
Correct Answer: B
Rationale: Urge suppression can lead to constipation, especially in postoperative patients.
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A nurse receives a report from an assistive personnel that a client's BP is 160/95. What should the nurse do first?
- A. Notify the healthcare provider
- B. Recheck the client's BP
- C. Document the findings
- D. Administer antihypertensive medication
Correct Answer: B
Rationale: The nurse should first reassess the client's BP to confirm the reading before taking any further action.
A community health nurse is teaching a group of clients about first aid for different types of wounds. Which of the following client statements indicates an understanding of the teaching?
- A. I should apply clean dressings over the top of blood-saturated dressings and hold pressure.
- B. I will rinse the wound with hot water to cleanse it.
- C. I can remove the dressing once the bleeding stops.
- D. I should apply antibiotic ointment directly to the wound.
Correct Answer: A
Rationale: Applying clean dressings over blood-saturated dressings and holding pressure helps prevent disruption of wound tissue.
A nurse is in the emergency department monitoring the hydration status of a client receiving oral rehydration. What should the nurse intervene for?
- A. Heart rate 120/min
- B. Urine output 30 mL/hour
- C. Blood pressure 110/70 mmHg
- D. Skin turgor is normal
Correct Answer: A
Rationale: A heart rate of 120/min may indicate dehydration or inadequate hydration, prompting the need for IV fluid replacement.
A nurse in a provider's office is assessing the motor skill development of a 15-month-old toddler during a well-child visit. What gross motor skills should the nurse expect?
- A. Walks without assistance using a wide stance
- B. Climbs stairs with assistance
- C. Runs smoothly
- D. Kicks a ball forward
Correct Answer: A
Rationale: At 15 months, toddlers typically walk independently but may do so with a wide stance for balance.
A nurse is assessing the IV infusion site of a client who reports pain at the site. The site is red and there is warmth along the course of the vein. What should the nurse do?
- A. Continue the infusion
- B. Increase the infusion rate
- C. Discontinue the infusion
- D. Apply a cold compress
Correct Answer: C
Rationale: The symptoms suggest phlebitis. The nurse should discontinue the infusion and may apply a warm compress.