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A nurse is caring for a client who is postoperative following a cesarean birth. Which of the following findings should the nurse report to the provider?
- A. The client reports pain at the incision site.
- B. The client's temperature is 38.5°C (101.3°F).
- C. The client has not voided in 6 hr.
- D. The client's lochia is moderate.
Correct Answer: B
Rationale: A temperature of 38.5°C suggests infection, requiring reporting. Pain, delayed voiding, and moderate lochia are expected or less urgent.
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A nurse is assisting with the admission of a client who has varicella zoster. Which of the following interventions should the nurse plan to implement?
- A. Administer aspirin if the client develops a fever.
- B. Initiate contact precautions for the client.
- C. Assign the client to a negative-pressure airflow room.
- D. Have visitors remain at least 0.91 m (3 feet. away from the client.
Correct Answer: C
Rationale: Varicella requires airborne precautions, including a negative-pressure room, to prevent spread. Aspirin risks Reye's syndrome, contact precautions alone are insufficient, and distance doesn't replace airborne measures.
A nurse is caring for a client who is receiving IV vancomycin. Which of the following findings should the nurse report to the provider?
- A. The client reports mild itching.
- B. The client's urine output is 40 mL/hr.
- C. The client's infusion site is red and warm.
- D. The client's blood pressure is 130/80 mm Hg.
Correct Answer: C
Rationale: Redness and warmth at the infusion site suggest phlebitis or infiltration, requiring reporting. Itching, normal urine output, and stable BP are less concerning.
A nurse is caring for a client who is postoperative following a TURP. Which of the following findings should the nurse report to the provider?
- A. The client reports a frequent urge to urinate.
- B. The client's urine is pink-tinged.
- C. The client's bladder irrigation fluid is clear.
- D. The client's urine output contains large clots.
Correct Answer: D
Rationale: Large clots in urine suggest hemorrhage, requiring immediate reporting. Urge to urinate, pink-tinged urine, and clear irrigation fluid are expected post-TURP.
A nurse is reinforcing teaching with a client who has a new prescription for amoxicillin. Which of the following instructions should the nurse include?
- A. Take this medication with an antacid to prevent stomach upset.
- B. You might experience diarrhea while taking this medication.
- C. You need to refrigerate this medication.
- D. You should stop taking this medication if you feel better.
Correct Answer: B
Rationale: Amoxicillin can cause diarrhea, a common side effect. Antacids aren't needed, refrigeration depends on form, and stopping early risks resistance.
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.