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A postoperative client with obesity and diabetes mellitus has an abdominal wound and is at risk for poor wound healing. Which of the following interventions does the nurse anticipate to prevent wound dehiscence? Select all that apply.
- A. Administer docusate sodium orally every day
- B. Assist in applying an abdominal binder
- C. Implement caloric restriction to promote weight loss
- D. Monitor blood glucose to maintain tight control
- E. Reinforce teaching to hug a pillow while coughing
Correct Answer: B, D, E
Rationale: Abdominal binder (B), glucose control (D), and pillow hugging (E) reduce wound stress and promote healing. Docusate (A) prevents constipation but not dehiscence, and caloric restriction (C) is inappropriate post-surgery.
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A woman has recently been diagnosed with multiple sclerosis. Which comment by the client indicates that she understands the nature of the disease process?
- A. I understand that recovery will be slow.'
- B. I am faithfully taking the medicines so the symptoms should disappear soon.'
- C. I will avoid being close to my grandchildren until I have been on medication for several months.'
- D. I bought a pretty cane to help me with balance when I am walking.'
Correct Answer: D
Rationale: Using a cane for balance shows understanding of multiple sclerosis' chronic, progressive nature causing mobility issues, unlike expecting full recovery or avoiding grandchildren.
The nurse is talking with the parent of a 22-month-old client. The parent states, 'I am worried about my child's thumb-sucking and its effects on tooth alignment.' Which of the following responses would be appropriate for the nurse to make? Select all that apply.
- A. Newer research demonstrates that thumb-sucking has little effect on a child's dentition.'
- B. Offer a security item such as a blanket to help your child self-soothe without thumb-sucking.'
- C. Provide positive reinforcement such as a sticker chart when your child avoids thumb-sucking.'
- D. The likelihood of needing braces because of thumb-sucking is significant when the behavior persists beyond 12 months of age.'
- E. The risk of malocclusion increases when thumb-sucking persists beyond the eruption of permanent teeth.'
Correct Answer: B, C, E
Rationale: Offering a security item (B), positive reinforcement (C), and noting malocclusion risk after permanent teeth erupt (E) are appropriate. Thumb-sucking has minimal effect before permanent teeth (A), and braces after 12 months (D) is exaggerated.
Laboratory reference ranges
Glucose (fasting)
Infant – Within 24 hours after birth
≥40 mg/dL (2.2 mmol/L)
The nurse is caring for assigned newborns. Which of the following newborns should the nurse check first?
- A. a newborn who was delivered 30 minutes ago and has bilateral crackles
- B. a newborn who was delivered 45 minutes ago and has asymmetric arm movement when the Moro reflex is tested
- C. a newborn who was delivered 6 hours ago and has a respiratory rate of 52/min
- D. a newborn who was delivered 12 hours ago, is jittery, and has a serum glucose level of 38 mg/dL (2.1 mmol/L)
Correct Answer: D
Rationale: A glucose level of 38 mg/dL with jitteriness (D) indicates hypoglycemia, a critical condition requiring immediate intervention. Crackles (A), asymmetric Moro reflex (B), and respiratory rate of 52 (C) are less urgent.
The nurse is talking with a client with atrial fibrillation who has a new prescription for dabigatran. Which of the following statements by the client would require follow-up?
- A. I should use a soft-bristled toothbrush when brushing my teeth.'
- B. I will notify my health care provider if I notice blood in my urine or stool.'
- C. I should swallow the medication capsule whole with a full glass of water.'
- D. I will have blood specimens obtained periodically while taking the medication.'
Correct Answer: D
Rationale: Dabigatran does not require routine blood monitoring (D), unlike warfarin, so this statement requires follow-up. Soft toothbrush (A), reporting bleeding (B), and swallowing whole (C) are correct.
The spouse of a client with Alzheimer's disease expresses concern about the burden of caregiving. Which of the following actions by the nurse should be a priority?
- A. Link the caregiver with a support group
- B. Ask friends to visit regularly
- C. Schedule a home visit each week
- D. Request anti-anxiety prescriptions
Correct Answer: A
Rationale: Assisting caregivers to locate and join support groups is most helpful. Families share feelings and learn about services such as respite care. Health education is also available through local and national Alzheimer's chapters.