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A nurse is caring for a client who is postoperative following a mastectomy. Which of the following actions should the nurse take to promote arm mobility?
- A. Encourage the client to perform deep breathing exercises.
- B. Instruct the client to avoid using the affected arm for 6 weeks.
- C. Teach the client to perform range-of-motion exercises daily.
- D. Apply a compression bandage to the affected arm.
Correct Answer: C
Rationale: Daily range-of-motion exercises prevent stiffness and promote mobility. Breathing exercises, arm avoidance, or compression don't target mobility.
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A nurse is caring for a client who is receiving oxygen at 2 L/min via nasal cannula. Which of the following actions should the nurse take?
- A. Apply petroleum jelly to the client's nares.
- B. Secure the cannula tubing behind the client's ears.
- C. Change the nasal cannula every 24 hr.
- D. Ensure the oxygen tubing is free of kinks.
Correct Answer: D
Rationale: Kink-free tubing ensures proper oxygen delivery. Petroleum jelly risks aspiration, securing tubing varies, and cannula changes aren't daily.
A nurse is caring for a client who is receiving IV fluids. Which of the following actions should the nurse take to prevent phlebitis?
- A. Change the IV site every 72 to 96 hr.
- B. Massage the IV site gently every 4 hr.
- C. Apply a cold compress to the IV site.
- D. Use a large-gauge catheter for fluid administration.
Correct Answer: A
Rationale: Changing the IV site every 72-96 hours reduces infection and phlebitis risk. Massaging, cold compresses, or large catheters don't prevent phlebitis.
A nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate. Which of the following actions should the nurse take?
- A. Monitor the client's urine output every 4 hr.
- B. Irrigate the catheter with sterile water every 2 hr.
- C. Check the catheter tubing for blood clots.
- D. Administer an antibiotic prophylactically.
Correct Answer: C
Rationale: Checking for clots ensures catheter patency, critical for irrigation. Output monitoring is secondary, manual irrigation isn't routine, and antibiotics depend on orders.
A nurse is caring for a client who is postoperative following a cesarean birth. Which of the following findings should the nurse report to the provider?
- A. The client reports pain at the incision site.
- B. The client's temperature is 38.5°C (101.3°F).
- C. The client has not voided in 6 hr.
- D. The client's lochia is moderate.
Correct Answer: B
Rationale: A temperature of 38.5°C suggests infection, requiring reporting. Pain, delayed voiding, and moderate lochia are expected or less urgent.
A nurse is reinforcing teaching with a client who has a new prescription for clopidogrel. Which of the following statements should the nurse include?
- A. Take this medication with food to prevent stomach upset.
- B. You might experience bruising more easily.
- C. You need to avoid eating citrus fruits.
- D. You should take this medication at bedtime.
Correct Answer: B
Rationale: Clopidogrel increases bleeding risk, leading to easy bruising. Food isn't required, citrus isn't restricted, and timing is flexible.