Nokea
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.
You may also like to solve these questions
A client with diabetes mellitus is receiving education from a nurse on preventing long-term complications. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will keep my blood glucose levels within the target range.
- B. I will check my feet daily for any open sores or wounds.
- C. I will monitor my blood pressure regularly.
- D. I will consume foods that are high in fiber.
Correct Answer: B
Rationale: The correct answer is B: 'I will check my feet daily for any open sores or wounds.' This statement shows an understanding of the importance of foot care in preventing complications like diabetic foot ulcers. Monitoring blood glucose levels (choice A) is crucial but not directly related to foot care. Monitoring blood pressure (choice C) is important for overall health but does not specifically address preventing long-term complications of diabetes. Consuming foods high in fiber (choice D) is beneficial for managing blood sugar levels but does not directly address preventing foot complications.
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 caring for a client who is 1 hr postoperative following a transurethral resection of the prostate (TURP). The nurse notes that the client's indwelling urinary catheter has not drained in the past hour. Which of the following actions should the nurse take?
- A. Irrigate the catheter with 0.9% sodium chloride.
- B. Reposition the catheter.
- C. Notify the provider.
- D. Increase the rate of the continuous bladder irrigation.
Correct Answer: A
Rationale: In this situation, the nurse should irrigate the catheter with 0.9% sodium chloride to help relieve any obstruction and ensure proper urinary drainage following a TURP. Repositioning the catheter may not address the underlying issue of obstruction. Notifying the provider should be done after attempting to resolve the drainage issue. Increasing the rate of continuous bladder irrigation is not the initial intervention for a catheter that is not draining.
A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse take?
- A. Insert the catheter 7.5 cm (3 in) into the urethra.
- B. Insert the catheter until urine flow is established.
- C. Cleanse the catheter with sterile water before insertion.
- D. Insert the catheter 5 cm (2 in) into the urethra.
Correct Answer: B
Rationale: The correct action for the nurse is to insert the catheter until urine flow is established. This helps ensure proper placement and reduces the risk of trauma. Choice A (7.5 cm) and Choice D (5 cm) provide specific measurements that may not be appropriate for all individuals as catheter insertion depth can vary. Choice C is incorrect as catheters should be cleansed with an appropriate solution such as sterile saline, not sterile water.
A nurse is providing discharge teaching to a client who has a new prescription for digoxin. Which of the following instructions should the nurse include?
- A. Take this medication at bedtime.
- B. Take your pulse before taking this medication.
- C. Avoid eating foods high in potassium.
- D. Take this medication with an antacid.
Correct Answer: B
Rationale: The correct instruction for the nurse to include is to advise the client to take their pulse before taking digoxin. This is important to monitor for bradycardia, a potential side effect of the medication. Option A is incorrect because digoxin is usually taken in the morning. Option C is unrelated to digoxin therapy, as high potassium foods are usually restricted in clients taking potassium-sparing diuretics. Option D is incorrect because digoxin should not be taken with antacids as they can affect its absorption.