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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.
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A nurse is reinforcing teaching with a client who has a new prescription for venlafaxine. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should take this medication with food.
- B. I might have headaches while taking this medication.
- C. I need to avoid caffeine.
- D. I can expect my mood to improve right away.
Correct Answer: B
Rationale: Venlafaxine can cause headaches, showing understanding. Food enhances absorption, caffeine isn't restricted, and mood improvement takes weeks.
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 craniotomy. Which of the following actions should the nurse take?
- A. Position the client flat in bed.
- B. Monitor the client's neurological status every 2 hr.
- C. Encourage the client to cough vigorously.
- D. Administer a stool softener as needed.
Correct Answer: B
Rationale: Frequent neurological checks detect complications like increased intracranial pressure early. Flat positioning risks pressure, vigorous coughing is avoided, and stool softeners prevent straining.
A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following findings should the nurse report to the provider?
- A. The client's blood glucose is 120 mg/dL.
- B. The client's temperature is 38.3°C (100.9°F).
- C. The client's weight increased by 0.5 kg overnight.
- D. The client reports mild discomfort at the IV site.
Correct Answer: B
Rationale: A temperature of 38.3°C suggests infection, possibly catheter-related, requiring reporting. Normal glucose, slight weight gain, and mild discomfort are less urgent.
A nurse is contributing to the plan of care for a client who is experiencing delirium. Which of the following interventions should the nurse recommend?
- A. Remind the client of the day and time often.
- B. Offer the client several choices at mealtimes.
- C. Avoid discussing the client's fears.
- D. Alternate daily caregivers.
Correct Answer: A
Rationale: Frequent orientation to time and place reduces confusion in delirium. Multiple choices can overwhelm, discussing fears supports emotional needs, and consistent caregivers minimize disorientation.