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The nurse assesses a large amount of red drainage on the dressing of a client who is six (6) hours postoperative open cholecystectomy. Which intervention should the nurse implement?
- A. Measure the abdominal girth.
- B. Palpate the lower abdomen for a mass.
- C. Turn client onto side to assess for further drainage.
- D. Remove the dressing to determine the source.
Correct Answer: D
Rationale: Removing the dressing to assess the source of red drainage (e.g., bleeding or dehiscence) is critical for timely intervention. Other actions are secondary to identifying the cause.
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A distal pancreatectomy and splenectomy is performed on a client with cancer of the pancreas. He is returned to his room postoperatively. The client is sleepy but can answer simple questions appropriately. His dressing is dry and intact. Vital signs are within normal limits. Which of the following nursing measures must be done before the nurse leaves the room?
- A. Inform his wife that he has returned to his room.
- B. Check to see if the indwelling urinary catheter bag is correctly attached to the bed frame.
- C. Assess to be sure he is not experiencing any discomfort.
- D. Put all four side rails in the high position.
Correct Answer: D
Rationale: Raising all four side rails ensures safety for a sleepy postoperative client, preventing falls.
Which medication should the nurse expect the HCP to order to treat the client diagnosed with botulism secondary to eating contaminated canned goods?
- A. An antidiarrheal medication.
- B. An aminoglycoside antibiotic.
- C. An antitoxin medication.
- D. An ACE inhibitor medication.
Correct Answer: C
Rationale: Botulism is treated with antitoxin to neutralize the toxin and prevent further paralysis. Antidiarrheals, antibiotics, and ACE inhibitors are inappropriate for botulism.
The male client tells the nurse he has been experiencing 'heartburn' at night that awakens him. Which assessment question should the nurse ask?
- A. How much weight have you gained recently?
- B. What have you done to alleviate the heartburn?
- C. Do you consume many milk and dairy products?
- D. Have you been around anyone with a stomach virus?
Correct Answer: B
Rationale: Asking what the client has done to alleviate the heartburn helps the nurse understand the severity, triggers, and any self-management strategies, which are critical for assessing GERD. Weight gain, dairy consumption, or exposure to a stomach virus are less directly related to the immediate assessment of heartburn symptoms.
The parents of a female toddler bring the child to the pediatrician's office with nausea, vomiting, and diarrhea. Which intervention should the nurse implement first?
- A. Ask the parent about the child's diet.
- B. Assess the child's tissue turgor.
- C. Give the child a sucker if she is good.
- D. Notify the HCP the child is waiting to be seen.
Correct Answer: B
Rationale: Assessing tissue turgor evaluates dehydration, a priority in a toddler with vomiting and diarrhea. Diet history, rewards, and HCP notification follow assessment.
The client is diagnosed with an acute exacerbation of ulcerative colitis. Which intervention should the nurse implement?
- A. Provide a low-residue diet.
- B. Rest the client's bowel.
- C. Assess vital signs daily.
- D. Administer antacids orally.
Correct Answer: B
Rationale: During an acute exacerbation of ulcerative colitis, resting the bowel (often via NPO status or clear liquids) reduces inflammation and irritation. A low-residue diet is used in stable phases, daily vital signs are routine, and antacids are irrelevant.