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An adult client who had a gastric bypass surgery is admitted with possible anastomosis leakage. The client's abdomen is tender to touch, and the vital signs are: temperature 38.3° C, heart rate 130 beats/minute, respiratory rate 20 breaths/minute, and blood pressure 100/50 mm Hg. Which intervention is most important for the nurse to include in the client's plan of care?
- A. Monitor skin for breakdown.
- B. Strict intravenous (IV) fluid replacement.
- C. Encourage regular turning.
- D. Assess wound drainage daily.
Correct Answer: B
Rationale: Strict IV fluid replacement is critical to manage hypovolemia and prevent sepsis in suspected anastomosis leakage.
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While assessing a patient with degenerative joint disease, the nurse notices Heberden's nodes, and large prominences on the patient's fingers that are reddened and painful. What should the nurse do?
- A. Discuss strategies for managing chronic pain with the patient.
- B. Check the patient's radial pulses and capillary refill time.
- C. Immediately notify the healthcare provider of the finding.
- D. Review the patient's dietary intake of high-protein foods.
Correct Answer: A
Rationale: Discussing chronic pain management strategies addresses the discomfort associated with Heberden's nodes, a common osteoarthritis feature.
A nurse is caring for a patient in the post-anesthesia care unit (PACU) who underwent a procedure two hours ago. The nurse observes the following vital signs: heart rate 140 beats/minute, blood pressure 140/90 mm Hg, and respirations 26 breaths/minute. Which intervention is most important for the nurse to implement?
- A. Apply oxygen at 10 L via non-rebreather mask and monitor pulse oximeter.
- B. Medicate for pain and monitor vital signs according to protocol.
- C. Encourage the client to splint the incision with a pillow to cough and deep breathe.
- D. Administer intravenous fluid bolus as prescribed by the healthcare provider.
Correct Answer: A
Rationale: Applying oxygen addresses potential hypoxia or respiratory distress indicated by the elevated vital signs.
A nurse is assessing a client who has an arteriovenous (AV) graft in the right forearm for hemodialysis access. The nurse auscultates a bruit over the graft area. Which intervention should the nurse implement?
- A. Document the findings.
- B. Elevate the extremity.
- C. Apply gentle pressure.
- D. Assess the client's temperature.
Correct Answer: A
Rationale: A bruit indicates a patent AV graft, a normal finding that should be documented.
A patient presents to the emergency department with nausea, vomiting, and diarrhea. During the history and physical, it is discovered that the patient's significant other is recovering from COVID-19. After obtaining a nasal swab to test the patient for COVID-19, what is the most important action for the nurse to take?
- A. Start an intravenous infusion for antiviral drug to be administered for positive COVID-19 test results.
- B. Move the patient to a private room, keep the door closed, and initiate droplet precautions.
- C. Notify the charge nurse that the patient will need assignment to the COVID-19 specified area of the facility.
- D. Explain to the patient to inform others that they may have been potentially exposed in the last 14 days.
Correct Answer: B
Rationale: Initiating droplet precautions in a private room prevents potential COVID-19 transmission pending test results.
The parent of an adolescent tells the clinic nurse, 'My child has athlete's foot. I have been applying triple antibiotic ointment for two days, but there has been no improvement.' Which instruction should the nurse provide?
- A. Antibiotics take two weeks to become effective against infections such as athlete's foot.
- B. Continue using the ointment for a full week, even after the symptoms disappear.
- C. Applying too much ointment can deter its effectiveness. Apply a thin layer to prevent maceration.
- D. Stop using the ointment and encourage complete drying of feet and wearing clean socks.
Correct Answer: D
Rationale: Athlete's foot is fungal, not bacterial; stopping antibiotic ointment and keeping feet dry with clean socks aids treatment.