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After receiving shift report, the nurse is assessing a client started on trimethoprim-sulfamethoxazole 2 days ago for treatment of a urinary tract infection. The client reports itching, and the nurse notices a diffuse maculopapular rash on the client's face. What should the nurse do first?
- A. Administer diphenhydramine
- B. Administer injectable epinephrine
- C. Examine the client's trunk and limbs
- D. Reassess the client's allergy history
Correct Answer: C
Rationale: Examining the trunk and limbs determines the rash’s extent, guiding whether it’s a mild reaction or a severe one (e.g., Stevens-Johnson syndrome). Diphenhydramine, epinephrine, or allergy reassessment are secondary until the rash is fully assessed.
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A client who had a bowel resection 5 days ago says, 'I felt like I split open when I coughed.' The nurse finds the incision edges separated and bowel protruding through the wound. Which of the following actions are appropriate? Select all that apply.
- A. Administer 1 oral tablet of oxycodone prescribed PRN for pain
- B. Collect a full set of vital signs
- C. Cover the viscera with sterile dressings saturated in normal saline solution
- D. Notify the health care provider immediately
- E. Place the client in the low Fowler position with knees slightly flexed
Correct Answer: B,C,D,E
Rationale: Vital signs, sterile saline dressings, provider notification, and low Fowler with flexed knees manage dehiscence and evisceration. Oxycodone is inappropriate during this emergency.
The nurse is talking with the parent of a 1-day-old newborn who had a circumcision using the plastic ring method. Which of the following statements by the parent would require follow-up?
- A. I will contact the health care provider if bleeding does not stop with gentle pressure
- B. I should avoid using alcohol-based cleansing wipes during diaper changes
- C. I need to leave the device in place and allow it to fall off on its own
- D. I understand that yellow exudate on the area is a sign of infection
Correct Answer: D
Rationale: Yellow exudate is normal during circumcision healing, not a sign of infection, requiring further teaching. Contacting the provider for persistent bleeding, avoiding alcohol wipes, and leaving the device are correct.
The nurse is collecting data from a client with a history of alcohol use disorder who had an emergency appendectomy 3 days ago. Which of the following findings would indicate that the client is experiencing delirium tremens? Select all that apply.
- A. Bradypnea
- B. Diaphoresis
- C. Hallucinations
- D. Lethargy
- E. Tachycardia
Correct Answer: B,C,E
Rationale: Delirium tremens presents with diaphoresis, hallucinations, and tachycardia due to autonomic hyperactivity. Bradypnea and lethargy are not typical; agitation is more common.
The nurse is caring for a client who had thoracic surgery yesterday and has a chest tube attached to water seal drainage. The client's family asks why he has to have a chest tube. What should the nurse include in the response?
- A. The chest tube allows air to enter the thoracic cavity to equalize pressures in the lung.
- B. The chest tube removes air from the pleural cavity and promotes reexpansion of the lung.
- C. The chest tube increases the amount of oxygen available to the lungs.
- D. The chest tube will help the wound heal faster and reduce scarring.
Correct Answer: B
Rationale: Chest tubes remove air/fluid from the pleural cavity, allowing lung reexpansion post-thoracic surgery. Other options misrepresent the tube's function.
When monitoring an infant with a left-to-right sided heart shunt, which findings would the nurse expect during the physical assessment? Select all that apply.
- A. Clubbing of fingertips
- B. Cyanosis when crying
- C. Diaphoresis during feedings
- D. Heart murmur
- E. Poor weight gain
Correct Answer: C,D,E
Rationale: Left-to-right shunts (e.g., VSD) cause pulmonary overcirculation, leading to diaphoresis, murmurs, and poor weight gain. Clubbing and cyanosis are more typical of right-to-left shunts.