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A nurse is caring for a client who is postoperative following a prostatectomy. Which of the following actions should the nurse take?
- A. Monitor the client's urine output every 2 hr.
- B. Instruct the client to resume a high-fiber diet immediately.
- C. Apply a cold pack to the perineal area.
- D. Encourage the client to sit for prolonged periods.
Correct Answer: A
Rationale: Monitoring urine output detects complications like obstruction. High-fiber diets resume gradually, cold packs aren't standard, and prolonged sitting risks discomfort.
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A nurse is caring for a client who is receiving IV vancomycin. Which of the following actions should the nurse take?
- A. Infuse the medication over 30 min.
- B. Monitor the client for tinnitus.
- C. Administer the medication with an antihistamine.
- D. Check the client's blood pressure every 4 hr.
Correct Answer: B
Rationale: Vancomycin can cause ototoxicity, so monitoring for tinnitus is essential. It's infused over 60-90 minutes, antihistamines aren't needed, and blood pressure checks aren't specific to vancomycin.
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 on a medical surgical unit is caring for a group of clients. Which of the following clients should the nurse see first?
- A. A client who is scheduled for surgery in 2 hr
- B. A client whose blood pressure is 160/90 mm Hg and reports a headache
- C. A client who is postoperative and reports intermittent nausea
- D. A client who is postoperative and has a Jackson Pratt drain
Correct Answer: B
Rationale: Elevated blood pressure with a headache suggests a hypertensive crisis, requiring immediate assessment to prevent complications like stroke. Other conditions are less urgent.
A nurse is caring for a client who is receiving IV fluids with potassium chloride. Which of the following findings should the nurse report to the provider?
- A. The client reports mild discomfort at the IV site.
- B. The client's heart rate is irregular.
- C. The client's urine output is 50 mL/hr.
- D. The client's blood pressure is 118/76 mm Hg.
Correct Answer: B
Rationale: An irregular heart rate suggests hyperkalemia or arrhythmia, requiring reporting. Mild discomfort, normal urine output, and stable BP are less concerning.
A nurse is reinforcing teaching with a client who has a new prescription for metoprolol. Which of the following statements should the nurse include?
- A. Take this medication with a high-fiber meal.
- B. You might feel tired while taking this medication.
- C. You need to avoid caffeine.
- D. You can stop taking this medication if your pulse is normal.
Correct Answer: B
Rationale: Metoprolol can cause fatigue, a side effect to anticipate. Fiber meals, caffeine avoidance, and stopping based on pulse aren't recommended.