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A nurse is caring for a client who is postoperative following a coronary artery bypass graft. Which of the following actions should the nurse take?
- A. Encourage the client to cough and deep breathe every 2 hr.
- B. Instruct the client to avoid using their arms for support.
- C. Apply a warm compress to the chest incision.
- D. Allow the client to resume a high-sodium diet.
Correct Answer: A
Rationale: Coughing and deep breathing prevent atelectasis and pneumonia. Arm use is encouraged with guidance, warm compresses risk infection, and sodium is restricted.
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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.
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.
A nurse is reinforcing teaching with new parents about car seat safety. Which of the following instructions should the nurse include?
- A. Keep the airbag on if the car seat is in the front seat.
- B. Position the car seat at a 90° angle.
- C. Put a small cushion under the newborn's head for support.
- D. Place the shoulder harnesses at the level of the infant's shoulders.
Correct Answer: D
Rationale: Shoulder harnesses at shoulder level ensure a secure fit, enhancing safety. Airbags should be off for front-seat car seats, the angle should be 45°, and cushions can disrupt proper positioning.
A nurse is caring for a client who is receiving IV heparin. Which of the following actions should the nurse take?
- A. Monitor the client's prothrombin time (PT).
- B. Administer the heparin via IV push.
- C. Check the client's activated partial thromboplastin time (aPTT).
- D. Instruct the client to increase vitamin K intake.
Correct Answer: C
Rationale: Heparin's effect is monitored via aPTT to ensure therapeutic anticoagulation. PT is for warfarin, heparin infuses slowly, and vitamin K counteracts it.
A nurse is assisting with the care of a client who is at 38 weeks of gestation and in active labor. Which of the following actions should the nurse take?
- A. Apply counterpressure to the client's sacrum during contractions.
- B. Position the client in a supine position during contractions.
- C. Encourage the client to take deep, cleansing breaths between contractions.
- D. Administer oxygen at 2 L/min via nasal cannula during contractions.
Correct Answer: C
Rationale: Deep breaths between contractions promote relaxation and oxygenation. Counterpressure may help some, supine position risks vena cava compression, and oxygen isn't routinely needed.