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A nurse is caring for a client who is 1 day postoperative following abdominal surgery. The nurse should suspect that the client has developed an infection based on which of the following findings?
- A. Blood pressure of 110/70 mm Hg
- B. Temperature of 38.5°C (101.3°F)
- C. Heart rate of 92/min
- D. Drainage at the surgical site
Correct Answer: B
Rationale: An elevated temperature of 38.5°C (101.3°F) is indicative of infection postoperatively. Fever is a common sign of infection, and temperatures above the normal range should raise suspicion. The other vital signs (blood pressure, heart rate) may be within an acceptable range, and some drainage at the surgical site can be expected postoperatively. However, the elevated temperature is a more specific indicator of a potential infection that requires immediate attention.
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A nurse is caring for a client who has received a new diagnosis of terminal cancer. The client tells the nurse, 'I just want to live long enough to see my child graduate.' The nurse should identify that the client is in which of the following stages of grief?
- A. Denial
- B. Bargaining
- C. Acceptance
- D. Anger
Correct Answer: B
Rationale: The client expressing a desire to live long enough to see their child graduate is an example of bargaining, which is a stage of grief where individuals attempt to negotiate for more time or different outcomes. Denial refers to refusing to accept the reality of the situation, acceptance involves coming to terms with the diagnosis, and anger is feeling frustrated and upset about the situation. Therefore, the correct answer is 'Bargaining.'
A nurse is reviewing the medical history of a client who has angina. What risk factor should the nurse identify?
- A. Hyperlipidemia.
- B. COPD.
- C. Seizure disorder.
- D. Hyponatremia.
Correct Answer: A
Rationale: The correct answer is A, Hyperlipidemia. Hyperlipidemia, characterized by high levels of lipids in the blood, is a well-established risk factor for the development of angina. Elevated lipid levels can lead to atherosclerosis, which narrows the arteries supplying the heart muscle with oxygenated blood, increasing the risk of angina. Choices B, C, and D are incorrect because COPD, seizure disorder, and hyponatremia are not directly associated with an increased risk of angina.
A client with diabetes mellitus is receiving discharge instructions from a nurse. Which statement by the client indicates an understanding of the teaching?
- A. I will monitor my blood sugar level once a week.
- B. I will exercise every day even if my blood sugar is low.
- C. I will eat snacks rich in carbohydrates if my blood sugar drops.
- D. I will avoid sugary foods to prevent my blood sugar from rising.
Correct Answer: C
Rationale: The correct answer is C. Eating snacks rich in carbohydrates is essential to manage hypoglycemia by raising blood sugar levels. Option A is incorrect as monitoring blood sugar once a week is not frequent enough for effective diabetes management. Option B is incorrect because exercising when blood sugar is low can worsen hypoglycemia. Option D is incorrect as it focuses on preventing high blood sugar levels, not managing low blood sugar.
A nurse is providing discharge teaching for a group of clients. The nurse should recommend a referral to a dietitian for which of the following clients?
- A. A client who has a prescription for warfarin and states, 'I will need to limit how much spinach I eat.'
- B. A client who has gout and states, 'I can continue to eat anchovies on my pizza.'
- C. A client who has a prescription for spironolactone and states, 'I will reduce my intake of foods that contain potassium.'
- D. A client who has osteoporosis and states, 'I'll plan to take my calcium carbonate with a full glass of water.'
Correct Answer: B
Rationale: The correct answer is B. A client with gout who plans to continue consuming anchovies should be referred to a dietitian for proper dietary education. Anchovies are high in purines, which can exacerbate gout symptoms. Choices A, C, and D do not require immediate dietitian referral as the statements made by these clients are appropriate actions regarding their prescribed medications (warfarin and spinach intake, spironolactone and potassium intake, and calcium carbonate and water intake, respectively).
A nurse is assessing a client who is postoperative following a bowel resection. Which of the following findings should the nurse report to the provider?
- A. Heart rate 110/min.
- B. Temperature of 37.4°C (99.3°F).
- C. Respiratory rate of 18/min.
- D. Urine output of 20 mL/hr.
Correct Answer: D
Rationale: A urine output of 20 mL/hr is below the expected range and indicates potential renal failure, requiring immediate intervention. In postoperative patients, a urine output less than 30 mL/hr suggests inadequate renal perfusion, a concern that needs prompt attention to prevent renal complications. The heart rate of 110/min, temperature of 37.4°C (99.3°F), and respiratory rate of 18/min are within normal ranges for a postoperative client and do not indicate immediate issues.