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A nurse is caring for a client who is postoperative following an appendectomy. 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 38.1°C (100.5°F).
- C. The client has not had a bowel movement since surgery.
- D. The client's incision is intact with minimal drainage.
Correct Answer: B
Rationale: A temperature of 38.1°C suggests possible infection, requiring reporting. Pain, no bowel movement, or minimal drainage are expected post-appendectomy.
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A nurse on a pediatric unit is caring for a toddler who has poor dietary intake. Which of the following actions should the nurse take first?
- A. Obtain the child's dietary history.
- B. Offer the child nutritious snacks between meals.
- C. Encourage the family to be with the child during mealtimes.
- D. Instruct the family to praise the child when they eat.
Correct Answer: A
Rationale: Obtaining a dietary history identifies patterns and causes of poor intake, guiding subsequent interventions like snacks or family involvement.
A nurse is reinforcing discharge teaching with the caregiver of a client who has a dependent personality disorder. Which of the following instructions should the nurse include in the teaching?
- A. Limit the client's social interactions.
- B. Encourage the client to be assertive.
- C. Assume responsibility for making the client's decisions.
- D. Maintain a verbal no-harm contract with the client.
Correct Answer: B
Rationale: Encouraging assertiveness promotes independence, countering dependency tendencies. Limiting interactions or making decisions for the client reinforces dependence, and no-harm contracts are unrelated.
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 caring for a client who is postoperative following a thyroidectomy. Which of the following actions should the nurse take?
- A. Monitor the client for neck swelling.
- B. Instruct the client to resume a high-iodine diet.
- C. Apply a heating pad to the surgical site.
- D. Encourage the client to speak loudly to test vocal cords.
Correct Answer: A
Rationale: Neck swelling post-thyroidectomy could indicate hematoma or edema, requiring monitoring. High-iodine diets, heating pads, and loud speaking aren't appropriate.
A nurse is caring for a client who has bulimia nervosa. Which of the following actions should the nurse take first?
- A. Observe the client during and after meals.
- B. Suggest that the client assist with meal planning.
- C. Instruct the client about effective coping strategies.
- D. Refer the client to a support group for clients who have eating disorders.
Correct Answer: A
Rationale: Observing during and after meals monitors for purging behaviors, a priority for safety in bulimia. Meal planning, coping strategies, and support groups follow after ensuring immediate safety.