Nokea
A young client with a postoperative abdominal abscess had a drain inserted. Which of the following assessments by the nurse is BEST?
- A. Amount of the drainage.
- B. Character of the drainage.
- C. Consistency of the drainage.
- D. Amount of suction on the drainage system.
Correct Answer: B
Rationale: with this complication, the character of the drainage, purulent or otherwise, is a major priority to note and report
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A three-month-old is placed in Bryant's traction for developmental dysplasia of the hips. Which of the following toys would be appropriate for the nurse to offer the infant during hospitalization?
- A. A rattle.
- B. A stuffed animal.
- C. Colorful blocks.
- D. A tape playing nursery rhymes.
Correct Answer: A
Rationale: three-month-old can grasp a rattle
An abdominal wound irrigation with a normal saline solution is ordered for a client. To perform this procedure, the nurse should
- A. warm the irrigating solution to 110°F (43.3°C).
- B. establish a sterile field that includes the irrigating equipment.
- C. direct the irrigating solution at the outer edges of the wound, then the center of the wound.
- D. aspirate the irrigating fluid with a syringe to prevent accumulation in the wound.
Correct Answer: B
Rationale: requires strict aseptic technique
A nurse discusses changes due to aging with a group at the senior citizen center. The nurse knows that which of the following changes in the pattern of urinary elimination normally occur with aging?
- A. Decreased frequency.
- B. Incontinence.
- C. Sphincter reflexes decrease.
- D. Formation of bladder stones.
Correct Answer: B
Rationale: ureters, bladder, and urethra lose muscle tone results in stress and urge incontinence
The nurse is caring for a patient hospitalized with an acute asthma attack. The nurse would be MOST concerned if which of the following was observed?
- A. The patient becomes more diaphoretic.
- B. The patient's respirations increase from 14 to 16 per minute.
- C. The patient's pulse increases from 86 to 100 beats per minute.
- D. The patient shows increasing pallor.
Correct Answer: C
Rationale: pulse increases due to decrease in oxygenation of tissues
A patient complains of pain after an appendectomy. After administering an analgesic, the nurse should take which of the following actions?
- A. Elevate the head of the bed 30-45°.
- B. Place a pillow behind the patient's knees.
- C. Elevate the knee gatch on the bed 30°.
- D. Lie the client supine with a small pillow under the head.
Correct Answer: A
Rationale: would reduce stress on suture line and provide for comfort