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A nurse is providing discharge teaching to a client who is postoperative following a laparoscopic cholecystectomy. Which of the following instructions should the nurse include?
- A. Resume a regular diet immediately.
- B. Remove the adhesive bandage after 3 days.
- C. Begin moderate activity immediately.
- D. Take a tub bath instead of a shower.
Correct Answer: B
Rationale: The correct answer is B. The adhesive bandage should be removed 3 days after a laparoscopic cholecystectomy to allow the incision to heal properly. Choice A is incorrect as the client should start with a clear liquid diet and advance to a regular diet as tolerated. Choice C is incorrect because the client should gradually increase activity levels as tolerated. Choice D is incorrect as the client should avoid tub baths and opt for showers to prevent infection and promote healing.
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A nurse is caring for a client who has pneumonia. Which of the following findings should the nurse report to the provider?
- A. Productive cough with green sputum
- B. Temperature of 37.1°C (98.8°F)
- C. Crackles in the lung bases
- D. Oxygen saturation of 95%
Correct Answer: C
Rationale: In a client with pneumonia, crackles in the lung bases can indicate fluid accumulation, worsening of the condition, or development of complications such as pulmonary edema. This finding should be reported to the provider promptly for further evaluation and management. Choices A, B, and D are common in clients with pneumonia and may not necessarily require immediate reporting unless accompanied by other concerning symptoms or vital sign abnormalities.
How should signs of infection in a post-surgical patient be assessed?
- A. Check the surgical site
- B. Check the patient's vital signs
- C. Monitor for fever
- D. Check for abnormal breath sounds
Correct Answer: A
Rationale: Assessing the surgical site is crucial in identifying early signs of infection post-surgery. Changes such as redness, swelling, warmth, or drainage may indicate an infection developing. While monitoring vital signs and fever are important in infection assessment, they are general indicators and may not show localized signs at the surgical site. Checking for abnormal breath sounds is more relevant when assessing respiratory issues rather than infection at the surgical site.
A patient refused a newly opened fentanyl patch. Which of the following actions should the nurse take?
- A. Ask another nurse to witness the disposal of the new patch
- B. Dispose of the patch in a sharps container
- C. Send the patch back to the pharmacy
- D. Document the refusal and remove the patch
Correct Answer: A
Rationale: When a patient refuses a newly opened fentanyl patch, the nurse should ask another nurse to witness the disposal of the new patch. This action ensures accountability, proper protocol, and prevents any potential diversion or misuse of the medication. Disposing of the patch in a sharps container (Choice B) is not sufficient as it does not address the need for witness accountability. Sending the patch back to the pharmacy (Choice C) may not be appropriate without proper documentation and witness. Simply documenting the refusal and removing the patch (Choice D) may lack the necessary verification of proper disposal.
A nurse is caring for a client who has deep vein thrombosis of the left lower extremity. Which of the following actions should the nurse take?
- A. Position the client with the affected extremity higher than the heart
- B. Administration of acetaminophen
- C. Massage the affected extremity every 4 hours
- D. Withhold heparin IV infusion
Correct Answer: D
Rationale: The correct action for the nurse to take when caring for a client with deep vein thrombosis is to withhold heparin IV infusion. Administering heparin is crucial in managing deep vein thrombosis by preventing further clot formation. Positioning the affected extremity higher than the heart (Choice A) promotes venous return and reduces swelling. Acetaminophen (Choice B) can be given for pain relief. Massaging the affected extremity (Choice C) is contraindicated as it can dislodge a clot, leading to serious complications.
How should a healthcare provider manage a patient who is experiencing acute pain?
- A. Administer analgesics as prescribed
- B. Reposition the patient to alleviate pain
- C. Offer non-pharmacological interventions
- D. Administer IV fluids
Correct Answer: A
Rationale: Corrected Rationale: Administering prescribed analgesics is the most effective way to manage acute pain. Analgesics help in reducing or eliminating pain quickly and efficiently. Repositioning the patient may be helpful in certain cases to relieve discomfort, but it is not the primary intervention for managing acute pain. Non-pharmacological interventions can be beneficial as adjuncts to pain management, but in cases of acute pain, administering analgesics is the priority. Administering IV fluids may be necessary for certain conditions but is not the primary intervention for managing acute pain.