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A nurse is caring for a client who is postoperative following a hysterectomy. Which of the following findings should the nurse report to the provider?
- A. The client reports mild vaginal bleeding.
- B. The client's temperature is 38.6°C (101.5°F).
- C. The client has not voided in 6 hr.
- D. The client's incision is intact with minimal drainage.
Correct Answer: B
Rationale: A temperature of 38.6°C suggests infection, requiring reporting. Mild bleeding, delayed voiding, and minimal drainage are expected or less urgent.
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A nurse is caring for a client who is postoperative following a craniotomy. Which of the following findings should the nurse report to the provider?
- A. The client reports a headache.
- B. The client's pupils are unequal.
- C. The client's incision has minimal drainage.
- D. The client's blood pressure is 130/85 mm Hg.
Correct Answer: B
Rationale: Unequal pupils suggest increased intracranial pressure or neurological deterioration, requiring reporting. Headache, minimal drainage, and normal BP are less urgent.
A nurse is reinforcing teaching with a client who has a new prescription for pantoprazole. Which of the following instructions should the nurse include?
- A. Take this medication at bedtime.
- B. You might experience diarrhea while taking this medication.
- C. You need to take this medication with an antacid.
- D. You should stop taking this medication if your symptoms improve.
Correct Answer: B
Rationale: Pantoprazole can cause diarrhea, a side effect to monitor. It's taken before meals, antacids aren't needed, and stopping early risks symptom recurrence.
A nurse is reinforcing teaching with a client who has a new prescription for amitriptyline. Which of the following statements should the nurse include in the teaching?
- A. You might experience weight loss while taking this medication.
- B. You should expect to have increased energy within a few days.
- C. You might feel drowsy, so avoid driving until you know how this medication affects you.
- D. You can stop taking this medication as soon as your symptoms improve.
Correct Answer: C
Rationale: Amitriptyline can cause drowsiness, so avoiding driving is prudent. Weight gain, not loss, is common, effects take weeks, and abrupt stopping risks relapse.
A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following findings should the nurse report to the provider?
- A. The client's blood glucose is 120 mg/dL.
- B. The client's temperature is 38.3°C (100.9°F).
- C. The client's weight increased by 0.5 kg overnight.
- D. The client reports mild discomfort at the IV site.
Correct Answer: B
Rationale: A temperature of 38.3°C suggests infection, possibly catheter-related, requiring reporting. Normal glucose, slight weight gain, and mild discomfort are less urgent.
A nurse is caring for a client who has end-stage kidney disease. The client has decided to stop dialysis treatment. Which of the following actions should the nurse take?
- A. Tell the client she should discuss this decision with her family.
- B. Support the client's decision to stop the treatment.
- C. Discuss alternative treatment methods with the client.
- D. Ask the facility chaplain to visit the client.
Correct Answer: B
Rationale: Supporting the client's decision respects autonomy, a core ethical principle. Discussing with family, alternatives, or involving a chaplain are secondary to honoring the client's choice.