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A nurse is caring for a client who is postoperative following a coronary artery bypass graft. Which of the following findings should the nurse report to the provider?
- A. The client reports chest discomfort.
- B. The client's temperature is 38.4°C (101.1°F).
- C. The client's incision has minimal drainage.
- D. The client's blood pressure is 130/80 mm Hg.
Correct Answer: B
Rationale: A temperature of 38.4°C suggests infection, requiring reporting. Chest discomfort, minimal drainage, and normal BP are expected or less urgent.
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A nurse is caring for a client who has been admitted to the mental health unit. While reinforcing teaching about the client's prescribed medications, the nurse communicates truthfully about the adverse effects of the medications. Which of the following ethical concepts is the nurse exhibiting?
- A. Justice
- B. Autonomy
- C. Veracity
- D. Beneficence
Correct Answer: C
Rationale: Veracity involves truthful communication. By honestly discussing medication side effects, the nurse upholds this principle, supporting informed decision-making.
A nurse is reinforcing teaching with a client who has a new prescription for metformin. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should take this medication on an empty stomach.
- B. I might need to check my blood sugar more often.
- C. I can stop taking this medication if I lose weight.
- D. I should avoid drinking alcohol while taking this medication.
Correct Answer: B,D
Rationale: Metformin requires frequent glucose monitoring and alcohol avoidance to prevent lactic acidosis. It's taken with food, and stopping needs provider approval.
A nurse is caring for a client who is postoperative following a total knee arthroplasty. Which of the following actions should the nurse take?
- A. Encourage the client to flex the knee every 2 hr.
- B. Apply a continuous passive motion machine as prescribed.
- C. Instruct the client to keep the leg in a dependent position.
- D. Administer a diuretic to reduce swelling.
Correct Answer: B
Rationale: A CPM machine promotes mobility and prevents stiffness as prescribed. Flexion timing varies, dependent positioning increases swelling, and diuretics aren't routine.
A nurse is assisting with preparing a client who is to have a central venous catheter inserted for the administration of total parenteral nutrition (TPN. Which of the following actions should the nurse take?
- A. Verify the amount of TPN solution the client is receiving every 4 hr.
- B. Prepare the client for a chest x-ray to verify catheter placement.
- C. Place the client in Sims' position for catheter insertion.
- D. Use a clean technique when changing the catheter dressing.
Correct Answer: B
Rationale: A chest X-ray confirms proper central venous catheter placement, critical for safe TPN administration. Verifying solution, Sims' position, or clean technique are inappropriate.
A nurse is caring for a client who is receiving IV heparin. Which of the following findings should the nurse report to the provider?
- A. The client reports mild bruising.
- B. The client's aPTT is 90 seconds.
- C. The client's blood pressure is 122/80 mm Hg.
- D. The client's urine output is 40 mL/hr.
Correct Answer: B
Rationale: An aPTT of 90 seconds (above therapeutic range of 60-80) suggests excessive anticoagulation, requiring reporting. Bruising, normal BP, and urine output are less urgent.