Nokea
The nurse admits a client newly diagnosed with hypertension. What is the best method for assessing the blood pressure?
- A. Standing and sitting
- B. In both arms
- C. After exercising
- D. Supine position
Correct Answer: B
Rationale: In both arms. This ensures accuracy, as stenosis in one subclavian artery could cause a false reading.
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The nurse is caring for a client who is postoperative day 1 after a cholecystectomy. Which of the following findings should the nurse report immediately?
- A. Mild pain at the incision site
- B. Temperature of 100.8°F (38.2°C)
- C. Bile-colored drainage from the T-tube
- D. Urine output of 40 mL/hour
Correct Answer: B
Rationale: A temperature of 100.8°F suggests infection, a serious post-cholecystectomy complication. Options A, C, and D are normal: pain is expected, bile drainage is typical, and urine output is adequate.
A primigravida client, 10-days postpartum, who is anxious about caring for her newborn. A middle-aged client, 6-days postoperative, who is complaining of pain in his midsternal incision. A client with AIDS who had a chest tube removed yesterday and is complaining of crackling under his skin. A client who receives amiloride hydrochloride (Midamor) and states that she is dizzy when she gets up in the morning.
The homecare nurse is scheduling clients for the day. Which of the following clients should the nurse visit FIRST?
- A. A primigravida client, 10-days postpartum, who is anxious about caring for her newborn.
- B. A middle-aged client, 6-days postoperative, who is complaining of pain in his midsternal incision.
- C. A client with AIDS who had a chest tube removed yesterday and is complaining of crackling under his skin.
- D. A client who receives amiloride hydrochloride (Midamor) and states that she is dizzy when she gets up in the morning.
Correct Answer: C
Rationale: Strategy: Identify the least stable client by eliminating the more stable clients. (1) psychosocial need, physical issues take priority (2) complaints require follow-up, but not the most unstable client (3) correct-describes subcutaneous emphysema, which is indication of pneumothorax; observe client for respiratory distress, contact physician (4) postural hypotension a side effect of diuretic therapy, change position slowly
The licensed practical nurse is caring for a 1-year old with a history of prematurity. Which developmental finding requires further evaluation by the physician?
- A. The child has been creeping for 3 months.
- B. The child can pull to a standing position.
- C. The child uses a pincer grasp.
- D. The child can sit with support.
Correct Answer: D
Rationale: Sitting with support at 1 year is delayed, especially for a preterm child, and requires evaluation. Creeping , standing , and pincer grasp are age-appropriate.
The nurse is caring for a client who is postoperative day 1 after a total hip replacement. Which of the following findings would be of GREATest concern to the nurse?
- A. Temperature of 100.8°F (38.2°C).
- B. Pain at the incision site.
- C. Leg swelling on the operative side.
- D. Urine output of 40 mL/hour.
Correct Answer: A
Rationale: A temperature of 100.8°F suggests infection, a serious complication post-hip replacement requiring immediate evaluation. Options B, C, and D are expected or less concerning: incision pain and leg swelling are normal, and urine output 40 mL/hour is adequate.
Immediately after surgery the client with an above-the-knee amputation of the right leg refuses to look at the operative site. The most immediate diagnosis that can be made is:
- A. Self-care deficit
- B. Potential for infection
- C. Disturbance in self-concept
- D. Cognitive deficit
Correct Answer: C
Rationale: Refusing to look at the operative site suggests a disturbance in self-concept, as the client may be struggling with acceptance of the altered body image post-amputation.