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A nurse is caring for a client who is postoperative following a femoral-popliteal bypass. Which of the following actions should the nurse take?
- A. Check the client's pedal pulses every 2 hr.
- B. Instruct the client to keep the affected leg in a dependent position.
- C. Apply a warm compress to the surgical site.
- D. Encourage the client to cross their legs when seated.
Correct Answer: A
Rationale: Checking pedal pulses assesses circulation, critical post-bypass. Dependent positioning risks swelling, warm compresses aren't standard, and leg crossing impairs flow.
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A nurse is caring for a client who is postoperative following a spinal fusion. Which of the following actions should the nurse take?
- A. Encourage the client to ambulate with a back brace.
- B. Instruct the client to twist at the waist when turning.
- C. Apply a heating pad to the surgical site.
- D. Allow the client to sit for 2 hr at a time.
Correct Answer: A
Rationale: A back brace supports ambulation, promoting stability. Twisting risks injury, heating pads may increase swelling, and prolonged sitting strains the spine.
A nurse is caring for a client who is receiving chemotherapy. Which of the following actions should the nurse take to prevent infection?
- A. Encourage the client to avoid fresh fruits and vegetables.
- B. Administer prophylactic antibiotics daily.
- C. Monitor the client's white blood cell count regularly.
- D. Instruct the client to avoid crowded places.
Correct Answer: C
Rationale: Monitoring WBC counts detects neutropenia early, guiding infection prevention. Fresh produce is safe if washed, antibiotics aren't routine, and avoiding crowds is secondary.
A nurse is caring for a client who is postoperative following a thyroidectomy. Which of the following findings should the nurse monitor for?
- A. Hypotension
- B. Hyperglycemia
- C. Hypocalcemia
- D. Bradycardia
Correct Answer: C
Rationale: Thyroidectomy risks hypoparathyroidism, leading to hypocalcemia, which can cause tetany or seizures. Hypotension, hyperglycemia, or bradycardia aren't primary concerns.
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.