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A nurse is caring for a client who is 3 days postoperative following an ileostomy placement. Which of the following findings should the nurse report to the provider?
- A. Stoma retracts into the abdominal wall.
- B. Stoma is a cherry red color.
- C. Stool contains scant red blood.
- D. Stool is a dark green color.
- E. Stoma is pale and dry.
- F. Stool is watery and excessive.
- G. Stoma is swollen and painful.
Correct Answer: A
Rationale: A retracted stoma is a complication requiring intervention; cherry red is normal, scant blood and dark green stool are expected early post-op.
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A nurse is reinforcing discharge teaching for a client who had a cerebrovascular accident (CVA) and requires assistance to perform their ADLs. Which of the following statements should the nurse provide?
- A. You will not become fatigued when you use assistive devices.
- B. Plan to hire a home care aid to perform all of your ADLs.
- C. Install grab bars in your shower to assist with your balance.
- D. Place a towel in the shower to prevent slipping.
Correct Answer: C
Rationale: Grab bars support balance and safety, key for CVA clients with ADL challenges. Other options are impractical or unsafe.
A nurse is assisting with the transfer of a client from a medical-surgical unit to an intensive care unit following a change in status. Which of the following information should the nurse include in the transfer documentation?
- A. Number of family members who have visited
- B. Primary health problem
- C. Admission vital signs from 1 week ago
- D. Scheduled times for dressing changes
- E. Current medication prescriptions
Correct Answer: B
Rationale: Transfer documentation ensures continuity of care, focusing on critical, current data for the receiving team. The primary health problem is essential it summarizes why the client's status changed (e.g., respiratory failure, sepsis), guiding ICU interventions. Number of family members who visited is irrelevant to clinical management; it's a social detail, not a priority. Admission vital signs from a week ago are outdated current vitals matter more, especially with a status change. Scheduled dressing changes are useful but secondary to understanding the underlying condition driving the transfer. Identifying the primary issue provides context for the client's deterioration, aligns with handoff standards like SBAR (Situation, Background, Assessment, Recommendation), and ensures the ICU team addresses the root cause immediately. This focus on relevance enhances patient safety, reduces miscommunication, and supports rapid response in a critical setting, making it the most vital piece of transfer information.
A nurse is reinforcing dietary teaching with an older adult client who has an increased LDL level. Which of the following foods should the nurse encourage the client to limit?
- A. Canola oil
- B. Swiss cheese
- C. Avocados
- D. Walnuts
- E. Olive oil
- F. Fatty fish
- G. Whole grains
Correct Answer: B
Rationale: Swiss cheese is high in saturated fat, raising LDL; canola oil, avocados, and walnuts are heart-healthy.
History and Physical
1000:
Client reports generalized weakness and increased fatigue over the past few months.
Client states they become short of breath after climbing a flight of stairs and are having difficulty keeping up with their grandchildren.
History of rheumatoid arthritis. Reports taking naproxen 500 mg twice a day.
Client reports they follow a vegan diet.
Denies pain or discomfort.
Bilateral breath sounds clear and present throughout.
Mucous membranes pale.
Apical pulse rapid, regular.
Which of the following findings require follow-up? (Client with generalized weakness, vegan diet, pale mucous membranes)
- A. Breath sounds
- B. Activity level
- C. Hematocrit
- D. Blood pressure
- E. Pain level
- F. Temperature
- G. Oxygen saturation
Correct Answer: B,C
Rationale: Decreased activity level and low hematocrit (24%) suggest anemia, requiring follow-up; breath sounds are clear, and other findings are less urgent.
A nurse is caring for a client who has a prescription for propranolol for the treatment of atrial fibrillation. Which of the following actions should the nurse take?
- A. Request a dosage increase if the apical heart rate is less than 60/min.
- B. Withhold the medication if the systolic blood pressure is less than 90 mm Hg.
- C. Administer the medication with an antacid.
- D. Instruct the client to expect increased hair growth.
Correct Answer: B
Rationale: Propranolol is a beta-blocker, and it should be withheld if the systolic blood pressure is below 90 mm Hg to prevent hypotension. A heart rate below 60/min might also warrant withholding, not increasing, the dose, and the other options are unrelated to its administration.