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A nurse is caring for a client who had a surgical repair of an abdominal aortic aneurysm 3 days ago. The clients vital signs are: temperature 38.3° C (100.9° F), heart rate 80/min, respirations 16/min, and blood pressure 128/76 mm Hg. Which of the following actions is the nurses priority?
- A. Administer an antipyretic for the fever.
- B. Encourage the client to ambulate.
- C. Assess the surgical incision for signs of infection.
- D. Increase IV fluid administration.
Correct Answer: C
Rationale: The correct answer is C: Assess the surgical incision for signs of infection. This is the priority because the client has a fever (indicating possible infection) post-surgery, putting them at risk for complications. Assessing the surgical incision allows for early detection of infection, prompt treatment, and prevention of further complications. Administering an antipyretic (choice A) only addresses the symptom but not the underlying cause. Encouraging ambulation (choice B) and increasing IV fluids (choice D) are important but assessing for infection takes precedence due to the potential severity of an infected surgical site.
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A nurse is monitoring a client following a lumbar laminectomy. The client has a drain and indwelling urinary catheter. The nurse should identify which of the following findings as an indication of a complication of the surgery?
- A. Red-tinged drainage on the dressing
- B. Cloudy urine in the catheter
- C. Clear drainage on the dressings
- D. Mild back pain at the surgical site
Correct Answer: C
Rationale: The correct answer is C: Clear drainage on the dressings. Clear drainage may indicate a cerebrospinal fluid leak, which is a serious complication following a lumbar laminectomy. Cerebrospinal fluid is a clear fluid that surrounds the brain and spinal cord, and its leakage can lead to infection and other complications. Red-tinged drainage (choice A) may be expected initially due to surgical trauma. Cloudy urine in the catheter (choice B) is more likely related to urinary tract infection. Mild back pain at the surgical site (choice D) is common after this surgery and does not necessarily indicate a complication.
A nurse is admitting an older adult client who is transferring from another facility. The nurse notes pressure ulcers on the clients coccyx and abrasions around both wrists. Which of the following actions should the nurse take to address suspicions of elder abuse?
- A. Notify risk management.
- B. Inform the transferring agency of the clients condition.
- C. Contact the family regarding the clients condition.
- D. Privately interview the client about the injuries.
Correct Answer: D
Rationale: Correct Answer: D - Privately interview the client about the injuries.
Rationale:
1. As a healthcare provider, the nurse must prioritize the well-being and safety of the client.
2. Privately interviewing the client allows for a confidential conversation to gather information directly from the client.
3. This approach respects the client's autonomy and confidentiality.
4. It enables the nurse to assess the situation, gather more details, and determine if further actions are needed to address the suspected elder abuse.
5. Notifying risk management (A) is important but should come after gathering information from the client.
6. Informing the transferring agency (B) may not address the immediate concern of potential abuse.
7. Contacting the family (C) may not be appropriate if they are involved in the abuse.
8. Failing to interview the client may result in a missed opportunity to address the issue effectively.
Summary:
Option D is correct as it prioritizes the client's well-being, respects autonomy, and
A nurse is teaching a client who has a new prescription for phenytoin to treat a seizure disorder. Which of the following adverse effects should the nurse instruct the client to report immediately to the provider?
- A. Drowsiness
- B. Gingival hyperplasia
- C. Skin rash
- D. Mild nausea
Correct Answer: C
Rationale: The correct answer is C: Skin rash. This is because phenytoin can cause severe and potentially life-threatening skin reactions like Stevens-Johnson syndrome or toxic epidermal necrolysis. These reactions can progress rapidly, so immediate medical attention is crucial. Drowsiness (A) is a common side effect of phenytoin but not typically an emergency. Gingival hyperplasia (B) and mild nausea (D) are common side effects that do not require immediate reporting.
A nurse is assessing a client who has right-sided heart failure. Which of the following findings should the nurse identify as a manifestation of right-sided heart failure?
- A. Crackles in the lungs
- B. Increased abdominal girth
- C. Pink frothy sputum
- D. Hypertension
Correct Answer: B
Rationale: The correct answer is B: Increased abdominal girth. In right-sided heart failure, the heart is unable to efficiently pump blood to the lungs for oxygenation, leading to fluid backup in the systemic circulation. This results in fluid retention, particularly in the abdomen, causing increased abdominal girth. Crackles in the lungs (choice A) are indicative of left-sided heart failure. Pink frothy sputum (choice C) is a sign of pulmonary edema, which is a manifestation of left-sided heart failure. Hypertension (choice D) is not typically associated with right-sided heart failure.
A nurse is caring for a client who has dumping syndrome following a gastric resection. The nurse should monitor the client for which of the following complications of dumping syndrome?
- A. Hyperkalemia
- B. Hypoglycemia
- C. Iron-deficiency anemia
- D. Hypertension
Correct Answer: C
Rationale: The correct answer is C: Iron-deficiency anemia. Dumping syndrome following a gastric resection can lead to rapid emptying of the stomach contents into the small intestine, causing malabsorption of nutrients, especially iron. Iron-deficiency anemia can develop due to inadequate iron absorption. Monitoring for anemia is crucial in these clients.
Hyperkalemia (A), hypoglycemia (B), and hypertension (D) are not typical complications of dumping syndrome. Hyperkalemia is high potassium levels, hypoglycemia is low blood sugar, and hypertension is high blood pressure, which are not directly associated with dumping syndrome.