Nokea
The client's temperature rises to 38°C (100.4°F) on the first postoperative day following abdominal surgery. The nurse interprets this to be:
- A. indicative of a wound infection.
- B. a normal physiological response to the trauma of surgery.
- C. suggestive of a urinary tract infection.
- D. an indication of overhydration.
Correct Answer: B
Rationale: A slight temperature elevation (100.4°F) on the first postoperative day is a normal response to surgical trauma.
You may also like to solve these questions
The nurse is administering morning medications at 0730. Which medication should have priority?
- A. A proton pump inhibitor.
- B. A nonnarcotic analgesic.
- C. A histamine receptor antagonist.
- D. A mucosal barrier agent.
Correct Answer: A
Rationale: Proton pump inhibitors (PPIs) are the mainstay treatment for GERD, reducing acid production and preventing esophageal damage. They should be prioritized over analgesics, histamine receptor antagonists, or mucosal barrier agents, which are less critical for immediate symptom control and healing.
The school nurse is discussing methods to prevent an outbreak of hepatitis A with a group of high school teachers. Which action is the most important to teach the high school teachers?
- A. Do not allow students to eat or drink after each other.
- B. Drink bottled water as much as possible.
- C. Encourage protected sexual activity.
- D. Sing the happy birthday song while washing hands.
Correct Answer: D
Rationale: Handwashing (e.g., for the duration of singing 'Happy Birthday') is the most effective way to prevent fecal-oral transmission of hepatitis A in a school setting. Sharing food/drink is a risk but less critical than hygiene.
The client is being prepared for discharge after a laparoscopic cholecystectomy. Which intervention should the nurse implement?
- A. Discuss the need to change the abdominal dressing daily.
- B. Tell the client to check the T-tube output every eight (8) hours.
- C. Include the significant other in the discharge teaching.
- D. Instruct the client to stay off clear liquids for two (2) days.
Correct Answer: C
Rationale: Including the significant other ensures support and reinforces discharge teaching for recovery. Daily dressing changes are unnecessary, T-tubes are not used in laparoscopic procedures, and clear liquids are encouraged.
The nurse has received the a.m. shift report. Which client should the nurse assess first?
- A. The 44-year-old client diagnosed with peptic ulcer disease who is complaining of acute epigastric pain.
- B. The 74-year-old client diagnosed with acute gastroenteritis who has had four (4) diarrhea stools during the night.
- C. The 65-year-old client diagnosed with IBD who has tented skin turgor and dry mucous membranes.
- D. The 15-year-old client diagnosed with food poisoning who has vomited several times during the night shift.
Correct Answer: C
Rationale: Tented skin turgor and dry mucous membranes in an elderly IBD patient indicate severe dehydration, a life-threatening condition requiring immediate assessment. Other clients have concerning but less urgent symptoms.
The nurse is teaching the client diagnosed with colon cancer who is scheduled for a colostomy. Which behavior indicates the nurse is utilizing adult learning principles?
- A. The nurse repeats the information as indicated by the client's questions.
- B. The nurse teaches in one session all the information the client needs.
- C. The nurse uses a video so the client can hear the medical terms.
- D. The nurse waits until the client asks questions about the surgery.
Correct Answer: A
Rationale: Repeating information based on client questions respects adult learning principles by addressing the learner’s needs and reinforcing understanding. One-session teaching, videos, or waiting for questions are less interactive.