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A nurse is collecting data from a client who has diabetes mellitus and reports foot pain. The nurse should evaluate the client for which of the following alterations as indications that the client has an infection? (Select all that apply.)
- A. Bradycardia
- B. An increase in platelets
- C. An increase in RBCs
- D. An increase in neutrophils
- E. Localized edema
Correct Answer: D,E
Rationale: D: An increase in neutrophils is a common response to bacterial infection. E: Localized edema indicates inflammation from infection. A, B, and C are not typical infection signs.
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A nurse is caring for a client who is experiencing postoperative nausea and vomiting. The nurse should monitor the client for which of the following complications of vomiting?
- A. Dehydration
- B. Urinary frequency
- C. Peripheral edema
- D. Diarrhea
Correct Answer: A
Rationale: Dehydration is a common complication of vomiting due to significant fluid loss.
A nurse is assisting with teaching a client who is on a low potassium diet. Which of the following instructions should the nurse include?
- A. Choose orange juice instead of apple juice.
- B. Replace sugar with molasses when baking.
- C. Eat granola for breakfast.
- D. Avoid using salt substitutes when cooking.
Correct Answer: D
Rationale: Salt substitutes contain potassium chloride, increasing potassium intake, which should be avoided.
A nurse is contributing to the plan of care for a client prescribed continuous enteral feedings. Which of the following actions should the nurse plan to take?
- A. Flush the tube with sterile sodium chloride solution every 2 hr.
- B. Change the feeding bag every 24 hr.
- C. Position the head of the client's bed at 15°.
- D. Check the gastric residual every 8 hr.
Correct Answer: B
Rationale: Changing the feeding bag every 24 hours prevents bacterial growth and infection, a standard practice for continuous feedings.
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 charge nurse in a long-term care facility will be implementing a new protocol to meet the Joint Commission's National Safety Goal of preventing health care-associated pressure ulcers. When informing the staff nurses about the new standard, the nurse should emphasize that which of the following actions is the priority?
- A. Identify the clients at greatest risk for development of pressure ulcers.
- B. Use a barrier cream when performing perineal care.
- C. Turn and position each client every 2 hr.
- D. Supervise clients to ensure adequate nutritional intake.
Correct Answer: A
Rationale: Identifying at-risk clients prioritizes preventive efforts for pressure ulcer management.