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A nurse is assessing a client who has had staples removed from an abdominal wound postoperatively. The nurse notes separation of the wound edges with copious light-brown serous drainage. Which of the following actions should the nurse perform first?
- A. Check the client's vital signs.
- B. Cover the wound with a moist, sterile gauze dressing.
- C. Assess the client's pain level.
- D. Obtain a culture and sensitivity of the wound drainage
Correct Answer: B
Rationale: Covering the wound with a moist, sterile dressing is the priority to protect it from infection and manage drainage, preventing further contamination and supporting healing.
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A nurse is preparing a plan of care for a client who is postoperative following a cochlear implant insertion. Which of the following instructions should the nurse include in the plan of care?
- A. Lie on your back when sleeping.
- B. Wash your hair 24 hr after surgery.
- C. Resume your exercise routine.
- D. Eat foods that are soft
Correct Answer: D
Rationale: Soft foods are recommended to avoid strain on the surgical site, reduce the risk of dislodging packing or stitches, and promote comfort during initial healing. Lying on the back is not necessarily required unless specified by the surgeon. Hair washing within 24-48 hours post-surgery risks infection. Exercise is typically restricted initially to prevent strain on the surgical area.
A nurse is monitoring a client who was admitted with a severe burn injury and is receiving IV fluid resuscitation therapy. The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement?
- A. Heart rate
- B. Weight
- C. Urine output
- D. BP
Correct Answer: A
Rationale: A decrease in heart rate indicates improved cardiac output and reduced tachycardia, suggesting adequate fluid replacement. Weight may increase, urine output should increase, and BP stabilizes but is less direct an indicator.
A nurse receives a unit of packed RBCs from a blood bank and notes that the time is 1130. The nurse should begin the infusion at which of the following times?
- A. 2 hr after obtaining blood from the blood bank
- B. When the client states he is ready to start the infusion
- C. As soon as the nurse can prepare the client and the administration set
- D. when the client has finished eating lunch
Correct Answer: C
Rationale: Blood products should be infused as soon as possible after preparation, ideally within 30 minutes, to reduce bacterial contamination risk and ensure efficacy.
While performing an admission assessment for a client, the nurse notes that the client has varicose veins with ulcerations and lower extremity edema with a report of a feeling of heaviness. Which of the following nursing diagnoses should the nurse identify as being the priority in the client's care?
- A. impaired skin integrity
- B. Alteration in activity tolerance
- C. Impaired tissue perfusion
- D. Alteration in body image
Correct Answer: C
Rationale: Impaired tissue perfusion is the priority because varicose veins, ulcerations, and edema suggest poor blood flow, which can lead to worsening complications. Addressing perfusion improves skin integrity and prevents further deterioration, making it more critical than activity tolerance or body image.
A nurse is caring for a client who has Meniere's disease. The nurse identifies which of the following manifestations is caused by an excessive accumulation of endolymph fluid?
- A. Myopia
- B. Vertigo
- C. Photophobia
- D. Presbycusis
Correct Answer: B
Rationale: Vertigo is a primary symptom of Meniere's disease, caused by excessive endolymph fluid in the inner ear affecting balance and spatial orientation. Myopia, photophobia, and presbycusis are unrelated to endolymph accumulation.