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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 administer an antibiotic.
- B. Administer an analgesic.
- C. Restrict fluid intake.
- D. Prepare to obtain a wound culture.
- E. Initiate supplemental oxygen.
Correct Answer: B
Rationale: Post-fasciotomy, pain from surgical incision and prior compartment pressure is expected, making analgesia a priority to enhance comfort and mobility, aiding recovery. Antibiotics are proactive for infection, but no fever or purulent drainage (Exhibit) justifies immediate use prophylaxis may apply, not routine post-op. Fluid restriction contradicts hydration needs for healing and circulation, especially with serosanguinous drainage. Wound cultures are indicated for infection signs (e.g., redness, pus), not routine here with a dry, intact dressing. Pain management aligns with postoperative care principles unrelieved pain increases stress, delays ambulation, and risks chronicity making analgesic administration the most immediate, evidence-based action to support the client's well-being and surgical outcome.
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A nurse is caring for a client who has returned to the unit following a cardiac catheterization using a femoral approach. Which of the following methods should the nurse use to monitor for complications?
- A. Palpate the client's brachial pulses and compare bilaterally.
- B. Check for jugular vein distention while the client is supine.
- C. Check the client's blood pressure while the client lies supine, sits, and stands.
- D. Palpate the client's pedal pulses and compare bilaterally.
- E. Monitor respiratory rate.
- F. Check for chest pain.
- G. Assess skin temperature.
Correct Answer: D
Rationale: Pedal pulses assess for femoral artery complications like hematoma or occlusion.
Exhibit 1 Exhibit 2 Exhibit 3 Exhibit 4 Exhibit 5
Diagnostic Results
1000:
Hct 24% (37% to 47%)
Hgb 8 g/dL (12 to 16 g/dL)
RBC count 3 x 10⁶ µL (4.2 to 5.4 x 10⁶ µL)
Ferritin 8 ng/mL (10 to 150 ng/mL)
WBC count 9,000/mm³ (5,000 to 10,000/mm³)
Platelet count 180,000/mm³ (150,000 to 400,000/mm³)
Vitamin B₁₂ 159 pg/mL (160 to 950 pg/mL)
1030:
Stool for fecal occult blood negative
A nurse is assisting in the care of the client who has iron deficiency anemia. Which of the following instructions should the nurse include?
- A. Take an antacid within 30 min after medication administration.
- B. Increase sources of fiber in the diet.
- C. Take the medication with a source of vitamin C.
- D. Increase intake of milk and dairy products.
- E. Take the medication on an empty stomach.
Correct Answer: C
Rationale: Iron deficiency anemia treatment hinges on maximizing iron absorption. Taking the medication with vitamin C enhances uptake ascorbic acid converts ferric to ferrous iron, boosting bioavailability in the acidic stomach environment, a cornerstone of anemia management. Antacids raise gastric pH, binding iron and reducing absorption, counterproductive to correcting deficiency. Increasing fiber mitigates constipation, a side effect of iron, but isn't the primary administration focus. Milk and dairy, high in calcium, inhibit iron absorption by competing for uptake sites, worsening anemia if paired with supplements. Vitamin C's synergistic effect backed by dietary guidelines optimizes therapy, especially critical with low ferritin (8 ng/mL, Exhibit 1), empowering the client to improve hemoglobin efficiently while minimizing common pitfalls, making it the essential instruction.
A nurse is reinforcing teaching with the partner of a client who has contact precautions in place for methicillin-resistant Staphylococcus aureus (MRSA). Which of the following statements by the partner indicates an understanding of the teaching?
- A. I can take my partner outside of the room as long as they wear a mask.
- B. I will wash my hands as soon as I leave the room.
- C. I will wear a gown when I help my partner take a bath.
- D. I will reuse unsoiled gloves when I re-enter the room.
Correct Answer: B
Rationale: Hand washing upon leaving prevents MRSA spread, a key contact precaution. Masks don't suffice, gowns are needed for bathing, and gloves must be fresh each entry.
A nurse is contributing to the plan of care for a client who is starting bowel training for the management of fecal incontinence. Which of the following interventions should the nurse recommend?
- A. Limit the client's physical activity until bowel continence is achieved.
- B. Assist the client to the restroom 30 min after meals.
- C. Instruct the client to limit their intake of high-fiber foods.
- D. Limit the client's fluid intake to 1500 mL/day
Correct Answer: B
Rationale: Bowel training aims to establish a regular pattern for defecation, particularly for clients with fecal incontinence, by leveraging the gastrocolic reflex, which increases intestinal motility after meals. Option A is incorrect because limiting physical activity does not promote bowel regularity and may worsen incontinence by reducing muscle tone. Option B is correct as assisting the client to the restroom 30 minutes after meals takes advantage of this reflex, encouraging predictable bowel movements and enhancing control over time. Option C is wrong since high-fiber foods aid bowel regularity by adding bulk to stool, which helps with continence, not hinders it. Option D is also incorrect adequate fluid intake (not restriction to 1500 mL/day) supports healthy stool consistency and prevents constipation, a key factor in incontinence management. Assisting post-meal aligns with physiological principles and patient-centered care, making it the best intervention for effective bowel training.
A nurse is assisting with the plan of care for a client who has osteoarthritis. The client reports knee stiffness upon ambulation. Which of the following interventions should the nurse include in the plan of care?
- A. Apply moist heat prior to ambulation.
- B. Delay ambulation until the next day
- C. Use a continuous passive motion machine
- D. Rest in a soft chair
- E. Apply cold packs.
- F. Increase weight-bearing exercise.
- G. Avoid all movement.
Correct Answer: A
Rationale: Moist heat reduces stiffness and improves mobility in osteoarthritis.