Nokea
A nurse is caring for a client whose hysterectomy wound has eviscerated. Which of the following actions should the nurse take?
- A. Turn the client onto her side.
- B. Cover the wound with a moist sterile dressing
- C. Apply an abdominal binder to the wound area.
- D. Assure the client that this is an expected occurrence after surgery.
Correct Answer: B
Rationale: Covering with a moist sterile dressing protects the wound and prevents infection in evisceration.
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A nurse is teaching the parents of a child who has diabetes mellitus about the manifestations of hypoglycemia. Which of the following manifestations should the nurse include in the teaching?
- A. Fruity breath odor
- B. Dry mucous membranes
- C. Diaphoresis
- D. Polyuria
Correct Answer: C
Rationale: Diaphoresis (sweating) is a classic sign of hypoglycemia due to sympathetic nervous system activation, unlike fruity breath (hyperglycemia) or polyuria (hyperglycemia).
A nurse is collecting data on a client who is experiencing hypervolemia. Which of the following findings should the nurse expect?
- A. Hypotension
- B. Peripheral edema
- C. Oliguria
- D. Bradycardia
Correct Answer: B
Rationale: Peripheral edema occurs in hypervolemia as excess fluid accumulates in tissues.
A nurse is preparing for a client who is at risk for a pressure injury. Which of the following actions should the nurse take?
- A. Elevate the head of the client's bed 45°
- B. Massage the client's bony prominences
- C. Provide the client with a high-calorie diet
- D. Reposition the client every 4 hrs
Correct Answer: C
Rationale: A high-calorie diet supports skin integrity and healing, reducing pressure injury risk.
A nurse is collecting data from a client who has an inadequate dietary intake of fiber. Which of the following findings should the nurse expect?
- A. Constipation
- B. Memory loss
- C. Brittle hair
- D. Bleeding gums
Correct Answer: A
Rationale: Low fiber intake slows digestion, leading to constipation.
A nurse is contributing to the plan of care for a client who has urinary incontinence. The nurse recommends monitoring the client for which of the following findings?
- A. Hypoglycemia
- B. Fluid volume overload
- C. Dermatitis
- D. Kidney stones
Correct Answer: C
Rationale: Dermatitis results from prolonged moisture exposure in incontinence, risking skin breakdown.