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.
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The client is diagnosed with end-stage liver failure. The client asks the nurse, 'Why is my doctor decreasing the doses of my medications?' Which statement is the nurse's best response?
- A. You are worried because your doctor has decreased the dosage.
- B. You really should ask your doctor. I am sure there is a good reason.
- C. You may have an overdose of the medications because your liver is damaged.
- D. The half-life of the medications is altered because the liver is damaged.
Correct Answer: D
Rationale: End-stage liver failure impairs drug metabolism, prolonging medication half-life, so doses are reduced to prevent toxicity. Overdose is a consequence, not the rationale, and other responses are less informative.
The dietitian and the nurse in a long-term care facility are planning the menu for the day. Which foods should be recommended for the immobile clients for whom swallowing is not an issue?
- A. Cheeseburger and milk shake.
- B. Canned peaches and a sandwich on whole-wheat bread.
- C. Mashed potatoes and mechanically ground red meat.
- D. Biscuits and gravy with bacon.
Correct Answer: C
Rationale: Mashed potatoes and ground meat are soft, low-fiber, and digestible, suitable for immobile clients to prevent constipation. Burgers, whole-wheat, and fatty foods are harder to digest.
The day after surgery in which a colostomy was performed, the client says, 'I know the doctor did not really do a colostomy.' The nurse understands that the client is in an early stage of adjustment to the diagnosis and surgery. What nursing action is indicated at this time?
- A. Agree with the client until the client is ready to accept the colostomy
- B. Say, 'It must be difficult to have this kind of surgery.'
- C. Force the client to look at his colostomy
- D. Ask the surgeon to explain the surgery to the client
Correct Answer: B
Rationale: Acknowledging the difficulty of the surgery supports the client emotionally during the denial stage without forcing confrontation.
The client has diarrhea that has been cultured positive for Clostridium difficile (C. diff). In order to prevent the spread of infection, the nurse should perform which intervention?
- A. Wear an isolation gown, gloves, and mask when providing care.
- B. Perform vigorous hand hygiene using only soap and water.
- C. Place the client in a private room with negative pressure airflow.
- D. Instruct visitors to use the alcohol-based hand wash for self-protection.
Correct Answer: B
Rationale: A. The nurse does not need to wear a mask when caring for the client; the bacterium is transmitted through direct contact. B. Hand washing with soap and water is performed instead of using alcohol—based hand cleaners; alcohol-based cleaners lack sporicidal activity. Even vigorous scrubbing with soap and water does not kill all of the spores. C. The client should be in a private room but does not need a negative pressure room. Negative pressure rooms are used with airborne diseases. D. The spores of C. diff can survive on inanimate objects such as tables and bedrails. For self-protection, visitors should be instructed to wash vigorously with soap and water and not to use the alcohol-based hand wash.
The nurse is assessing the client who is 24 hours post—GI hemorrhage. The findings include BUN of 40 mg/dL and serum creatinine of 0.8 mg/dL. Which action should be taken by the nurse?
- A. Immediately call the health care provider to report these results.
- B. Monitor urine output, as this may be a sign of kidney failure.
- C. Document the findings and continue to monitor the client.
- D. Encourage the client to limit his or her dietary protein intake.
Correct Answer: C
Rationale: A. No treatment is required; it is unnecessary to call the HCP. B. If acute kidney failure is present, both the BUN and creatinine would be elevated. C. The findings should be documented. The BUN can be elevated after a significant GI hemorrhage from the breakdown of blood proteins. The protein breakdown releases nitrogen that is then converted to urea. D. Limiting protein intake in the presence of healthy kidneys is unnecessary.