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A nurse is caring for a client who is postoperative following a right radical mastectomy. Which of the following actions should the nurse take to prevent the development of lymphedema?
- A. Keep both arms below the level of the client's heart.
- B. Obtain blood pressure readings using the client's right arm.
- C. Use the client's left arm to obtain blood samples.
- D. Limit range-of-motion exercises with the affected arm
Correct Answer: C
Rationale: Using the left arm for blood samples avoids trauma to the right arm, reducing the risk of lymphedema after a right mastectomy.
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A nurse is assisting in the care of a client following a tonsillectomy who is alert and has an SpO2 of 93% on room air. Which of the following actions should the nurse take?
- A. Obtain the client's peak expiratory flow volume.
- B. Encourage the client to cough.
- C. Place the client in a semi-Fowler's position.
- D. Encourage the client to use a straw to sip cool liquids.
Correct Answer: C
Rationale: Placing the client in a semi-Fowler's position promotes airway clearance and comfort post-tonsillectomy, especially with an SpO2 of 93%.
A nurse is caring for a client who is 6 hr postoperative following a bowel resection. Which of the following findings is the priority for the nurse to report?
- A. The client arouses easily but quickly falls back asleep.
- B. There is 20 mL of dark red drainage from the wound drainage device over the past 4 hr.
- C. There is 60 mL of dark yellow urine from the indwelling urinary catheter over the past 4 hr.
- D. The client reports a pain level of 6 on a scale from 0 to 10 at the incision site.
Correct Answer: A
Rationale: Difficulty staying awake 6 hours post-op suggests potential respiratory depression or neurological issues, a priority to report.
A nurse is assisting a provider with a thoracentesis for a client who is experiencing respiratory distress. Which of the following actions should the nurse take?
- A. Insert an indwelling urinary catheter and record the client's output.
- B. Set up the equipment using clean technique.
- C. Prepare the client for a chest x-ray following the procedure.
- D. Instruct the client to remain flat in bed for 4 to 6 hr after the procedure.
Correct Answer: C
Rationale: A chest x-ray post-thoracentesis confirms lung re-expansion and checks for complications like pneumothorax.
A nurse is reviewing the results of a client's fecal occult blood screening test. Which of the following findings from the client's history should the nurse identify as potentially causing a false-positive result?
- A. The client had a hemorrhoidectomy 1 year ago.
- B. The client takes ibuprofen for headaches.
- C. The client consumed citrus juice 3 days before the test.
- D. The client has a history of breast cancer.
Correct Answer: B
Rationale: Ibuprofen, an NSAID, can irritate the gastrointestinal tract and cause minor bleeding, potentially leading to a false-positive fecal occult blood test result.
A nurse is reinforcing teaching with the family of a client who has methicillin-resistant Staphylococcus aureus (MRSA) of a leg wound and is on contact precautions. Which of the following statements by a family member indicates an understanding of the teaching?
- A. There is no cure for MRSA.
- B. We will need to wear masks when we are in the hospital room.
- C. MRSA only occurs in health care facilities.
- D. We should remove gloves before leaving the hospital room.
Correct Answer: D
Rationale: Removing gloves before leaving prevents the spread of MRSA, consistent with contact precautions.