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A nurse is assessing a client who is 48 hours postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?
- A. Serosanguineous drainage on the surgical dressing.
- B. Temperature of 37.8°C (100°F).
- C. Urine output of 75 mL in the past 4 hours.
- D. WBC count of 15,000/mm³.
Correct Answer: D
Rationale: The correct answer is D. An elevated WBC count can indicate a potential infection, especially in a postoperative client. This finding should be reported to the provider for further evaluation and management. Choices A, B, and C are common occurrences in postoperative clients and may not necessarily indicate a severe issue. Serosanguineous drainage on the surgical dressing is a normal finding in the immediate postoperative period. A temperature of 37.8°C (100°F) can be a mild fever, which is common postoperatively due to the body's response to tissue injury. Urine output of 75 mL in the past 4 hours may be within normal limits for a postoperative client, especially if they are still recovering from anesthesia.
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A client has Clostridium difficile infection. Which of the following actions should the nurse take?
- A. Wash hands with an alcohol-based hand rub.
- B. Place the client on contact precautions.
- C. Wear a mask when entering the client's room.
- D. Double-bag all linens before removing them from the room.
Correct Answer: B
Rationale: The correct action for the nurse to take when caring for a client with Clostridium difficile infection is to place the client on contact precautions. This helps prevent the spread of the infection to other clients. Washing hands with an alcohol-based hand rub is important for infection control but is not specific to preventing the spread of Clostridium difficile. Wearing a mask may be necessary for airborne precautions but is not the priority for Clostridium difficile infection. Double-bagging linens is not a standard practice for preventing the spread of Clostridium difficile.
A nurse is reviewing the laboratory results of a client who is at 36 weeks of gestation. The nurse should report which of the following laboratory results to the provider?
- A. Hemoglobin 11.2 g/dL
- B. Platelet count 148,000/mm3
- C. Leukocyte count 9,000/mm3
- D. Blood glucose 80 mg/dL
Correct Answer: A
Rationale: A hemoglobin level of 11.2 g/dL is below the normal range for a client who is 36 weeks gestation and should be reported to the provider.
A client receiving warfarin is being taught by a nurse. Which of the following client statements indicates an understanding of the teaching?
- A. I will avoid eating leafy green vegetables while taking this medication.
- B. I will need to have my INR checked regularly while taking this medication.
- C. I will take this medication at the same time each day.
- D. I will avoid taking aspirin while taking this medication.
Correct Answer: D
Rationale: The correct answer is D because clients taking warfarin should avoid aspirin to reduce the risk of bleeding, as both medications can thin the blood. Choice A is incorrect because it is essential to eat a consistent amount of leafy green vegetables to maintain a steady intake of Vitamin K, which can impact warfarin's effectiveness. Choice B is incorrect although important because INR checks are necessary but do not specifically show an understanding of the teaching. Choice C is incorrect because while taking warfarin at the same time each day is beneficial for consistency, it does not directly address the interaction with aspirin.
A client is receiving discharge instructions following a stroke. Which of the following client statements indicates an understanding of the teaching?
- A. I will avoid using aspirin for pain.
- B. I will consume dairy products to increase my calcium intake.
- C. I will drink 1.5 to 2 liters of fluid each day.
- D. I will need to limit my intake of fiber.
Correct Answer: A
Rationale: The correct answer is A. Avoiding aspirin is crucial for this client as it can increase the risk of bleeding after a stroke. Choice B about consuming dairy products for calcium intake is not directly related to stroke management. Choice C regarding fluid intake is a good practice for overall health but not specifically related to stroke care. Choice D about limiting fiber intake is not typically a concern after a stroke unless there are specific complications that warrant it.
A nurse is providing teaching to a client who has diabetes mellitus and a new prescription for insulin glargine. Which of the following instructions should the nurse include?
- A. You should inject this medication once a day, at the same time each day.
- B. You should expect your blood glucose level to increase immediately after administration.
- C. You should rotate injection sites between your abdomen and thigh.
- D. You should inject this medication with your meals.
Correct Answer: A
Rationale: The correct instruction that the nurse should include is to inject insulin glargine once a day, at the same time each day. Insulin glargine is a long-acting insulin that provides a consistent level of insulin over 24 hours, helping to maintain stable blood glucose levels. Option B is incorrect because insulin glargine does not cause an immediate increase in blood glucose levels. Option C is important for preventing lipodystrophy but is not specific to insulin glargine administration. Option D is incorrect because insulin glargine is typically administered at the same time each day, regardless of meals.