Nokea
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. Maintain abduction of the client's residual limb with a pillow.
- B. Encourage the client to use the overbed trapeze.
- 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: B
Rationale: Using an overbed trapeze builds upper body strength, aiding independent repositioning. Abduction, avoiding prone positions, or loose dressings don't directly enhance mobility.
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A nurse is caring for a client who has been admitted to the mental health unit. While reinforcing teaching about the client's prescribed medications, the nurse communicates truthfully about the adverse effects of the medications. Which of the following ethical concepts is the nurse exhibiting?
- A. Justice
- B. Autonomy
- C. Veracity
- D. Beneficence
Correct Answer: C
Rationale: Veracity involves truthful communication. By honestly discussing medication side effects, the nurse upholds this principle, supporting informed decision-making.
A nurse is caring for a client who is postoperative following a coronary artery bypass graft. Which of the following findings should the nurse report to the provider?
- A. The client reports chest discomfort.
- B. The client's temperature is 38.4°C (101.1°F).
- C. The client's incision has minimal drainage.
- D. The client's blood pressure is 130/80 mm Hg.
Correct Answer: B
Rationale: A temperature of 38.4°C suggests infection, requiring reporting. Chest discomfort, minimal drainage, and normal BP are expected or less urgent.
A nurse is caring for a client who is postoperative following a prostatectomy. Which of the following actions should the nurse take?
- A. Monitor the client's urine output every 2 hr.
- B. Instruct the client to resume a high-fiber diet immediately.
- C. Apply a cold pack to the perineal area.
- D. Encourage the client to sit for prolonged periods.
Correct Answer: A
Rationale: Monitoring urine output detects complications like obstruction. High-fiber diets resume gradually, cold packs aren't standard, and prolonged sitting risks discomfort.
A nurse is caring for a client who is postoperative following a bowel resection. Which of the following findings should the nurse report to the provider?
- A. The client reports mild abdominal discomfort.
- B. The client's bowel sounds are hypoactive.
- C. The client's incision is red and warm to the touch.
- D. The client has passed flatus.
Correct Answer: C
Rationale: Redness and warmth at the incision suggest infection, requiring prompt reporting. Mild discomfort, hypoactive sounds, and flatus are expected post-resection.
A nurse is reinforcing teaching about laboratory testing with a client. Which of the following findings should the nurse include as an indicator of infection?
- A. Decreased platelets
- B. Increased iron level
- C. Increased erythrocyte sedimentation rate
- D. Decreased hemoglobin
Correct Answer: C
Rationale: Increased ESR indicates inflammation, often due to infection. Platelet or hemoglobin decreases or iron increases aren't specific to infection.