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A nurse is caring for a client who is postoperative following a cholecystectomy. Which of the following findings should the nurse report to the provider?
- A. The client reports shoulder pain.
- B. The client's temperature is 38.2°C (100.8°F).
- C. The client has not had a bowel movement since surgery.
- D. The client's incision is intact with slight redness.
Correct Answer: B
Rationale: A temperature of 38.2°C suggests infection, requiring reporting. Shoulder pain is referred pain, no bowel movement is expected, and slight redness is normal.
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The nurse is reviewing the medical record of a client who has a new prescription for zolpidem. Which of the following findings should the nurse identify as a potential contraindication for this medication?
- A. History of migraines
- B. Current use of sertraline
- C. Seasonal allergies
- D. History of sleepwalking
Correct Answer: D
Rationale: Zolpidem can exacerbate sleepwalking, making it a contraindication. Migraines, sertraline, or allergies don't pose significant risks with zolpidem.
A nurse is caring for a preschooler who recently experienced the death of a parent. Which of the following findings should the nurse identify as consistent with this age group?
- A. Understands that everyone dies eventually
- B. Recognizes the parent will never wake up
- C. Expresses curiosity about the funeral service
- D. Believes death is punishment for bad behavior
Correct Answer: D
Rationale: Preschoolers often believe death is a punishment due to magical thinking. Understanding permanence or universal death is beyond their developmental stage.
A nurse is reinforcing discharge teaching with a client who has a prescription for antibiotic therapy. The client reports experiencing diarrhea when taking antibiotics. Which of the following foods should the nurse recommend to lessen the occurrence of diarrhea?
- A. Coffee
- B. Ice cream
- C. Apple juice
- D. Yogurt
Correct Answer: D
Rationale: Yogurt's probiotics help restore gut flora, reducing antibiotic-associated diarrhea. Coffee, ice cream, and apple juice may worsen diarrhea due to their diuretic, lactose, or sugar content.
A nurse is caring for a client who is receiving IV chemotherapy. Which of the following findings should the nurse report to the provider?
- A. The client reports mild fatigue.
- B. The client's IV site is cool and swollen.
- C. The client's urine output is 200 mL over 4 hr.
- D. The client's temperature is 37.2°C (99°F).
Correct Answer: B
Rationale: A cool, swollen IV site suggests extravasation, a chemotherapy emergency requiring immediate reporting. Fatigue, urine output, and mild fever are less urgent.
A nurse is caring for a client who is receiving a unit of packed red blood cells. Which of the following actions should the nurse take?
- A. Infuse the blood over 6 hr.
- B. Check the client's temperature every 30 min.
- C. Administer the blood through a 22-gauge IV catheter.
- D. Flush the IV line with dextrose 5% in water before infusion.
Correct Answer: B
Rationale: Monitoring temperature every 30 minutes detects transfusion reactions early. Blood infuses over 2-4 hours, requires a large-gauge catheter, and saline, not dextrose, is used.