Nokea
A nurse is caring for a client who is postoperative following a bowel resection. Which of the following actions should the nurse take?
- A. Encourage the client to ambulate as tolerated.
- B. Instruct the client to avoid coughing.
- C. Apply a warm compress to the incision site.
- D. Administer a diuretic every 4 hr.
Correct Answer: A
Rationale: Ambulation prevents complications like ileus and thromboembolism. Coughing aids lung function, warm compresses risk infection, and diuretics aren't routine.
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A nurse is collecting data from a client who is 1 day postoperative following a transurethral resection of the prostate. Which of the following findings should the nurse report to the provider?
- A. Urine output of 300 ml over 8 hr.
- B. Occasional small clots in the urine
- C. Dark red urine
- D. Frequent urge to urinate
Correct Answer: C
Rationale: Dark red urine may indicate hemorrhage, a serious complication requiring immediate reporting. Urine output of 300 mL over 8 hours is adequate, small clots are expected, and frequent urge to urinate is common post-procedure.
A nurse is caring for a client who has a new prescription for furosemide. Which of the following laboratory values should the nurse monitor?
- A. Sodium
- B. Calcium
- C. Potassium
- D. Magnesium
Correct Answer: C
Rationale: Furosemide can cause hypokalemia, so potassium levels must be monitored. Sodium, calcium, or magnesium aren't primarily affected.
A nurse is caring for a client who is postoperative following a hysterectomy. Which of the following findings should the nurse report to the provider?
- A. The client reports mild vaginal bleeding.
- B. The client's temperature is 38.6°C (101.5°F).
- C. The client has not voided in 6 hr.
- D. The client's incision is intact with minimal drainage.
Correct Answer: B
Rationale: A temperature of 38.6°C suggests infection, requiring reporting. Mild bleeding, delayed voiding, and minimal drainage are expected or less urgent.
A nurse is reinforcing teaching with a client who has a new prescription for lorazepam. Which of the following instructions should the nurse include?
- A. You should take this medication in the morning.
- B. You might experience dizziness while taking this medication.
- C. You need to increase your fluid intake while taking this medication.
- D. You can take this medication with an antacid.
Correct Answer: B
Rationale: Lorazepam can cause dizziness, a key safety concern. Timing is flexible, fluid increase isn't needed, and antacids don't interact significantly.
A nurse is reinforcing teaching with a client who has hypertension and a new prescription for hydrochlorothiazide. Which of the following instructions should the nurse include?
- A. Increase your intake of potassium-rich foods.
- B. Take the medication at bedtime.
- C. Monitor for leg cramps.
- D. Limit your fluid intake to 1 liter daily.
Correct Answer: C
Rationale: Hydrochlorothiazide can cause hypokalemia, leading to leg cramps, which should be monitored. Potassium intake may need adjustment, it's taken in the morning, and fluid limits aren't standard.