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A postoperative client has a Jackson-Pratt drain. Which finding should the nurse report immediately?
- A. Clear, serous drainage.
- B. Bright red drainage of 50 mL in 2 hours.
- C. Slight swelling around the drain site.
- D. Drainage with a foul odor.
Correct Answer: B
Rationale: Bright red drainage suggests active bleeding, a serious complication requiring immediate reporting.
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The nurse is assessing a newborn 24 hours after birth. Which finding requires immediate reporting?
- A. Milia on the nose
- B. Mongolian spots on the back
- C. Caput succedaneum
- D. Yellowing of the skin
Correct Answer: D
Rationale: Yellowing of the skin within 24 hours suggests pathological jaundice, requiring immediate evaluation to prevent complications like kernicterus.
A client with Alzheimer's disease is started on a low dose of lorazepam (Ativan) because of agitation and a sleep disturbance. The nurse should assess the client for which of the following?
- A. Nightingale agitation
- B. Extrapyramidal side effects
- C. Vomiting
- D. Anticholinergic side effects
Correct Answer: D
Rationale: Lorazepam, a benzodiazepine, can cause anticholinergic side effects such as dry mouth, constipation, or confusion, especially in elderly clients with Alzheimer's. Extrapyramidal effects are associated with antipsychotics, and vomiting is less common.
The registered nurse, prior to the delegation of tasks to other members of the nursing care team, evaluates the ability of staff members to perform assigned tasks for the position as based on which legal consideration?
- A. The American Nurses Association's Scopes of Practice
- B. The American Nurses Association's Standards of Care
- C. State statutes
- D. Federal law
Correct Answer: C
Rationale: Delegation of tasks by a registered nurse must comply with state statutes , which define the scope of practice and delegation authority for nurses and other healthcare team members within each state. These laws ensure that tasks are delegated to individuals who are legally qualified to perform them.
Which of the following skin care instructions would be appropriate for a client receiving radiation therapy?
- A. Avoid shaving with straight-edge razors.
- B. Clean the skin daily with antibacterial soap.
- C. Apply moisturizing lotion before and after each treatment.
- D. Keep the radiated area covered with a sterile gauze dressing.
Correct Answer: A
Rationale: Avoiding straight-edge razors prevents skin irritation in the radiated area, which is sensitive.
The nurse performing tracheostomy care has replaced the tracheostomy tube holder (tracheostomy ties). Which is an effective measure for the nurse to use when determining if the holder is not too tight?
- A. The client nods that he or she feels comfortable.
- B. Two fingers can be slid comfortably under the holder.
- C. Four fingers can be slid comfortably under the holder.
- D. The tracheostomy does not move more than 0.5 inch when the client coughs.
Correct Answer: B
Rationale: There should be enough room for two fingers to slide comfortably under the tracheostomy holder. This ensures that the holder is tight enough to prevent tracheostomy dislocation, while preventing excessive constriction around the neck. The other options are incorrect.