Nokea
A nurse is caring for a client who is postoperative following an appendectomy. Which of the following information should the nurse include when documenting in the electronic medical record?
- A. Abdominal wound dry, without redness
- B. Client received an adequate amount of fluid
- C. Client status unchanged throughout shift
- D. Incision healing well
- E. Pain level stable
- F. No fever noted
- G. Ambulated without difficulty
Correct Answer: A
Rationale: Specific, objective data like 'dry, without redness' is required; vague terms like 'adequate' or 'unchanged' are insufficient.
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An occupational health nurse is interpreting the results of a tuberculin skin test for a group of clients who received the test 48 hr ago. Which of the following clients should the nurse identify as having a positive test result?
- A. A client whose injection site is scabbed
- B. A client whose injection site is firm and measures 3 mm (0.1 in)
- C. A client whose injection site has an elevated area measuring 15 mm (0.6 in)
- D. A client whose injection site is ecchymotic
Correct Answer: C
Rationale: An induration of 15 mm after 48 hours indicates a positive TB skin test, suggesting exposure or infection. Smaller indurations, scabbing, or bruising do not meet the criteria for a positive result.
Diagnostic Results
Day 1:
X-ray of right leg: open spiral tibial shaft fracture
For each finding, click to specify if the finding is consistent with acute compartment syndrome, infection, and/or fat embolism syndrome. Finding: Dyspnea
- A. Dyspnea
- B. Tingling sensation to right foot
- C. Increased pain at incision site
- D. Swelling at incision site
Correct Answer:
Rationale: Dyspnea is a hallmark of fat embolism syndrome due to pulmonary involvement.
A nurse is reinforcing discharge teaching for a client who had a cerebrovascular accident (CVA) and requires assistance to perform their ADLs. Which of the following statements should the nurse provide?
- A. You will not become fatigued when you use assistive devices.
- B. Plan to hire a home care aid to perform all of your ADLs.
- C. Install grab bars in your shower to assist with your balance.
- D. Place a towel in the shower to prevent slipping.
Correct Answer: C
Rationale: Grab bars support balance and safety, key for CVA clients with ADL challenges. Other options are impractical or unsafe.
A nurse is reinforcing teaching with a client who has heart failure and a new prescription for furosemide. The nurse should instruct the client to monitor for which of the following adverse effects?
- A. Rhinitis
- B. Metallic taste
- C. Ringing in ears
- D. Agitation
- E. Weight gain
- F. Dry cough
- G. Blurred vision
Correct Answer: C
Rationale: Ringing in ears (tinnitus) is a sign of furosemide ototoxicity; rhinitis and metallic taste aren't typical.
A nurse is assisting in the care of a client who is postoperative following an open reduction internal fixation of the right tibia. The first action the nurse should take is to...
- A. notify the provider of increased pain followed by elevating the extremity at level of the heart.
- B. check the client's oxygen saturation followed by administering pain medication.
- C. assess the client's incision site followed by applying a cold pack.
- D. monitor the client's vital signs followed by documenting the findings.
Correct Answer: A
Rationale: Post-ORIF, increased pain (Day 2, 1600) suggests compartment syndrome, a surgical emergency requiring immediate provider notification to evaluate for fasciotomy. Elevating the extremity at heart level balances perfusion without worsening pressure, unlike high elevation which reduces blood flow. Checking oxygen saturation and medicating pain address symptoms, not the cause pain here signals ischemia, not hypoxia. Assessing the incision (e.g., swelling) supports suspicion, but notification trumps delay; cold packs may mask signs. Monitoring vital signs is routine, but pain's acuity demands action over documentation. Prompt reporting aligns with the 6 Ps, prioritizing limb salvage, making it the critical first step.