Nokea
Postoperatively, which of the following client concerns should be the nurse's highest priority?
- A. Pain
- B. Waiting
- C. Anxiety
- D. Fatigue
Correct Answer: A
Rationale: Pain is a priority as it may indicate complications like infection or graft failure.
You may also like to solve these questions
Which of the following clients should have his clothing removed immediately?
- A. A 32-year-old man who was burned while working on high-tension wires
- B. A 14-year-old boy who suffered severe smoke inhalation during a fire at school
- C. A 78-year-old man who was burned during a fire that started when the client fell asleep while smoking
- D. A 19-year-old student who spilled chemicals on himself in the chemistry lab at school
Correct Answer: D
Rationale: Clothing must be removed immediately in chemical burns to prevent further skin exposure and damage from the corrosive substance.
The nurse and an unlicensed assistive personnel (UAP) are caring for clients in a dermatology clinic. Which task should not be delegated to the UAP?
- A. Stock the rooms with the equipment needed.
- B. Weigh the clients and position the clients for the examination.
- C. Discuss problems the client has experienced since the previous visit.
- D. Take the biopsy specimens to the laboratory.
Correct Answer: C
Rationale: Discussing client problems requires nursing judgment, outside UAP scope. Stocking, weighing/positioning, and transporting specimens are appropriate.
The school nurse is preparing to teach a health promotion class to high school seniors. Which information regarding self-care should be included in the teaching?
- A. Wear a sunscreen with a protection factor of 10 or less when in the sun.
- B. Try to stay out of the sun between 0300 and 0500 daily.
- C. Perform a thorough skin check monthly.
- D. Remember caps and long sleeves do not help prevent skin cancer.
Correct Answer: C
Rationale: Monthly skin checks detect early skin cancer changes. SPF 10 is inadequate, 0300–0500 is nighttime, and caps/long sleeves are protective.
The nurse and an unlicensed assistive personnel (UAP) are caring for a client with a stage IV pressure ulcer. Which action by the UAP warrants intervention by the nurse?
- A. The UAP turns the client every two (2) hours.
- B. The UAP keeps the sheets wrinkle free.
- C. The UAP encourages the client to drink high-protein drinks.
- D. The UAP places multiple diapers on the client.
Correct Answer: D
Rationale: Multiple diapers increase moisture and pressure, worsening stage IV ulcers. Turning, wrinkle-free sheets, and protein drinks are appropriate.
The client comes to the emergency department complaining of pain in the left lower leg following a puncture wound from a nail in a board. The left lower leg is reddened with streaks, edematous, and hot to the touch, and the client has a temperature of 100.8°F. Which condition would the nurse suspect the client is experiencing?
- A. Cellulitis.
- B. Lyme disease.
- C. Impetigo.
- D. Deep vein thrombosis.
Correct Answer: A
Rationale: Redness, edema, heat, and streaks post-puncture suggest cellulitis, a bacterial infection. Lyme disease has a bullseye rash, impetigo is superficial, and DVT lacks skin changes.