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A nurse is assisting with the care of a client who is receiving a spinal epidural to treat a herniated disc. Which of the following findings should the nurse identify as an indicator of unrelieved pain?
- A. Difficulty swallowing
- B. Constipation
- C. Urinary retention
- D. Clenched teeth
Correct Answer: D
Rationale: Clenched teeth indicate ongoing pain despite the epidural.
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The client has heart failure and is taking furosemide.
A nurse is collecting data from a client who has heart failure and is taking furosemide. Which of the following findings should indicate to the nurse that the medication is effective?
- A. Increased urinary output
- B. Decreased hemoglobin level
- C. Increased weight of 0.91 kg (2 lb)
- D. Decreased BUN level
Correct Answer: A
Rationale: Increased urinary output reflects furosemide's diuretic effect, reducing fluid overload.
The client states that she slipped on some water outside of the shower.
A nurse enters a client's room and finds her sitting on the floor next to the shower. The client states that she slipped on some water outside of the shower. Which of the following actions should the nurse take first?
- A. Notify the client's provider.
- B. Measure the client's vital signs.
- C. Document the fall in the client's medical record.
- D. Complete an incident report.
Correct Answer: B
Rationale: Measuring vital signs assesses for immediate injury, the priority action.
A nurse is caring for a client who is 2 days postoperative following an above-the-knee amputation. Which of the following actions should the nurse take to promote progression toward independence and mobility for the client?
- A. Encourage the client to use the overbed trapeze.
- B. Maintain abduction of the client's residual limb with a pillow.
- C. Caution the client to avoid a prone position while in bed.
- D. Keep a loose, absorbent dressing over the client's surgical site.
Correct Answer: A
Rationale: Using the trapeze builds upper body strength for mobility.
A nurse is providing site care for a child who has a gastrostomy enteral tube. Which of the following actions should the nurse take?
- A. Tape the tube to the child's cheek.
- B. Attach an extension tube to the site's opening prior to use.
- C. Secure the tubing to the child's abdomen.
- D. Apply water-soluble lubricant to the site.
Correct Answer: C
Rationale: Securing the tube to the abdomen prevents dislodgement.
A nurse is reinforcing teaching with new parents about car seat safety. Which of the following instructions should the nurse include?
- A. Place the shoulder harnesses at the level of the infant's shoulders.
- B. Put a small cushion under the newborn's head for support.
- C. Position the car seat at a 90-degree angle.
- D. Keep the airbag on if the car seat is in the front seat.
Correct Answer: A
Rationale: Shoulder harnesses at shoulder level ensure proper restraint fit.