Nokea
The nurse is admitting a client to the unit from the postoperative recovery area after abdominal exploratory surgery.
After determining the client's vital signs, which of the following activities should the nurse perform next?
- A. Position the client on her left side, supported with pillows.
- B. Check the chart and determine the status of the fluid balance from surgery.
- C. Check the client's abdominal dressing for any evidence of bleeding.
- D. Monitor the incision and pulmonary status for the presence of infection.
Correct Answer: C
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. (1) implementation, complete assessment first (2) assessment, determine what is happening to the patient now (3) correct-assessment, dressing should be checked on admission to the room and frequently for the next several hours (4) inappropriate assessment, it is too soon for infection to occur secondary to surgery
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A three-year-old boy was shown to have delays on the Denver Development Screening Test (DDST).
Which of the following responses by the nurse is BEST?
- A. Maybe he is just having a bad day. I'm sure he will do much better next time.
- B. The Test indicated a delay and we will have to investigate to learn more.
- C. What are your thoughts about how your child performed on the Test ?
- D. The results may not be accurate. Let's set up a time to reTest your child.
Correct Answer: C
Rationale: Strategy: 'BEST' indicates that fine discrimination is required. The topic of the questions is unstated. Determine topic by reading the answer choices. (1) nontherapeutic, false reassurance (2) factual but closed communication (3) correct-open-ended, encourages discussion (4) doesn't encourage discussion of concerns
The homecare nurse is visiting a young adult with a diagnosis of hepatitis A. Which of the following statements, if made by the client to the nurse, indicates that further teaching is needed?
- A. I have been very careful to wash my hands after I go to the bathroom.
- B. I have had to take Tylenol several times this week for this sinus infection I have.
- C. I have been very careful not to handle my child's toys or eating utensils.
- D. My husband has been preparing all of the meals since I've been sick.
Correct Answer: B
Rationale: Tylenol (acetaminophen) is hepatotoxic and should be avoided in hepatitis A, which impairs liver function, indicating a need for further teaching. Options A, C, and D show correct precautions to prevent oral-fecal transmission.
A bipolar patient refuses to put down the mop that he is swinging to threaten other patients and staff.
What information is MOST important for the nurse to consider before administering a PRN IM dose of lorazepam (Ativan)?
- A. The patient is harmful to himself.
- B. The patient is psychotic.
- C. A restrictive intervention failed.
- D. The patient is harmful to others.
Correct Answer: C
Rationale: Strategy: Think about each answer choice. (1) use the least restrictive interventions in ascending order (2) use the least restrictive interventions in ascending order (3) correct-use the least restrictive interventions in ascending order (4) use the least restrictive interventions in ascending order
A young female with recent ileostomy due to ulcerative colitis. A middle-aged male with elevated temperature and chronic pancreatitis. A teenager in hypovolemic shock following a crushing injury to the chest. A child with compound fracture of the right femur and massive laceration of the left arm.
The nurse would identify which of the following patients as a likely candidate for developing acute renal failure?
- A. A young female with recent ileostomy due to ulcerative colitis.
- B. A middle-aged male with elevated temperature and chronic pancreatitis.
- C. A teenager in hypovolemic shock following a crushing injury to the chest.
- D. A child with compound fracture of the right femur and massive laceration of the left arm.
Correct Answer: C
Rationale: Strategy: Determine how each answer choice relates to acute renal failure. (1) usually ileostomy clients do not experience severe hypovolemia, which would lead to renal failure problems (2) this type of infection and inflammation does not lead to acute renal failure (3) correct-common cause of acute renal failure is renal ischemia precipitated by hypovolemia or heart failure (4) femoral fractures are more likely to lead to fat embolism than acute renal failure
The nurse is developing a meal plan that would provide the maximum possible amount of iron for a child with anemia. Which dinner menu would be best?
- A. Fish sticks, french fries, banana, cookies, milk
- B. Ground beef patty, lima beans, wheat roll, raisins, milk
- C. Chicken nuggets, macaroni, peas, cantaloupe, milk
- D. Peanut butter and jelly sandwich, apple slices, milk
Correct Answer: B
Rationale: Iron rich foods include red meat, fish, egg yolks, green leafy vegetables, legumes, whole grains, and dried fruits such as raisins. This dinner is the best choice. It is high in iron and is appropriate for a toddler.