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A nurse is caring for a client 24h post-op following abdominal surgery and suspects inadequate pain management. Which findings support this suspicion?
- A. Client seems easily agitated
- B. Client is nonadherent with coughing and deep breathing
- C. Client accepts pain medication every 6-7h instead of 4-6h
- D. Client reports tenderness in right lower leg
- E. Client's vital signs: HR 110/min
Correct Answer: B,C,E
Rationale: The correct answer is B, C, and E. Choice B indicates nonadherence with coughing and deep breathing, which is essential for preventing postoperative complications such as pneumonia. Choice C suggests the client is not taking pain medication as frequently as prescribed, indicating inadequate pain relief. Choice E shows an elevated heart rate, which can be a sign of uncontrolled pain. Choices A and D do not directly relate to inadequate pain management post-op. A client being agitated (choice A) can have various causes, and tenderness in the right lower leg (choice D) is not specific to poor pain management.
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Nurse is giving presentation about accident prevention to group of parents & toddlers. Which strategies should nurse include? (Select all that apply.)
- A. Keep toxic agents in locked cabinets
- B. Keep toilet seats up
- C. Turn pot handles toward back of stove
- D. Place safety gates across stairways
- E. Make sure balloons are fully inflated
Correct Answer: A,C,D
Rationale: The correct answers are A, C, and D. A) Keeping toxic agents in locked cabinets prevents toddlers from accessing harmful substances. C) Turning pot handles toward the back of the stove prevents toddlers from accidentally pulling them down. D) Placing safety gates across stairways prevents toddlers from falling down stairs. B) Keeping toilet seats up increases the risk of toddlers falling in. E) Having balloons fully inflated poses a choking hazard. In summary, choices A, C, and D are important strategies for accident prevention, while choices B and E can actually increase risks for toddlers.
Nurse preparing wellness presentation for families at community center. When discussing health screenings for adolescents, which info about scoliosis should nurse include? (Select all that apply.)
- A. Scoliosis is more common in girls than in boys
- B. Loss of height is often first sign of scoliosis
- C. Scoliosis screening is essential during adolescent growth spurt
- D. Slouching is common cause of scoliosis, especially in adolescents
- E. Scoliosis is forward curvature of spine
Correct Answer: A,C
Rationale: Correct Answer: A, C
A: Scoliosis is more common in girls than in boys - This is correct. Scoliosis is indeed more prevalent in girls compared to boys, with a ratio of about 7:1.
C: Scoliosis screening is essential during adolescent growth spurt - This is correct. Screening during the adolescent growth spurt is crucial as this is when scoliosis progression is most likely to occur.
B: Loss of height is often first sign of scoliosis - This is incorrect. The first sign of scoliosis is typically asymmetry or a visible curvature of the spine.
D: Slouching is a common cause of scoliosis, especially in adolescents - This is incorrect. Slouching is not a direct cause of scoliosis; it can exacerbate existing curvature but does not cause scoliosis.
E: Scoliosis is a forward curvature of the spine - This is incorrect. Scoliosis involves a lateral (side
Nurse planning diversionary activities for children on peds unit. Which should nurse incorporate as appropriate play activities for school-age children? (Select all that apply.)
- A. Building models
- B. Playing video games
- C. Reading books
- D. Using toy carpentry tools
- E. Shaping modeling clay
Correct Answer: A,B,C
Rationale: The correct activities for school-age children should be developmentally appropriate and engaging. Building models (A) promotes creativity and fine motor skills. Playing video games (B) can be stimulating and entertaining. Reading books (C) encourages literacy and imagination. Toy carpentry tools (D) may pose safety risks. Shaping modeling clay (E) is suitable but less interactive than the correct choices. In summary, A, B, and C are the best options for promoting active engagement and development in school-age children.
Nurse on med-surg unit is informed that mass casualty event occurred & it's necessary to discharge clients to make beds available for injury victims. Which clients can be safely discharged? (Select all that apply.)
- A. Client who's dehydrated & receiving IV fluid/electrolytes
- B. Client with NG tube to treat small bowel obstruction
- C. Client who's scheduled for TURP (prostate resection)
- D. Client who is 24h post-op after mastectomy
- E. Client scheduled for appendectomy
Correct Answer: C,D
Rationale: The correct answers are C and D.
C: The client scheduled for a TURP (transurethral resection of the prostate) can be safely discharged as this surgery is elective and not urgent.
D: The client who is 24 hours post-op after a mastectomy can also be discharged as they are stable and beyond the immediate post-operative phase.
A: Client receiving IV fluids for dehydration should not be discharged as they require ongoing treatment and monitoring.
B: Client with an NG tube for a small bowel obstruction should not be discharged as they require close observation and treatment.
E: Client scheduled for an appendectomy should not be discharged as this procedure is likely urgent and may require immediate attention.
A home health nurse is discussing dangers of carbon monoxide poisoning with a client. What information should the nurse include?
- A. Carbon monoxide has a distinct odor
- B. Water heaters should be inspected every 5 years
- C. Lungs are damaged from carbon monoxide inhalation
- D. Carbon monoxide binds with hemoglobin in body
Correct Answer: D
Rationale: The correct answer is D: Carbon monoxide binds with hemoglobin in the body. This is correct because carbon monoxide binds with hemoglobin in the blood more easily than oxygen, leading to decreased oxygen delivery to tissues. This can result in symptoms of carbon monoxide poisoning.
A: Carbon monoxide is odorless, so this is incorrect.
B: While regular inspection of appliances like water heaters is important for safety, it is not directly related to carbon monoxide poisoning.
C: Carbon monoxide primarily affects the body by interfering with oxygen transport, not by directly damaging the lungs.
In summary, choice D is correct because it explains the mechanism of carbon monoxide poisoning, while the other choices are incorrect as they do not directly relate to the dangers of carbon monoxide poisoning.