Nokea
The nurse is assessing a client with suspected appendicitis. Which of the following findings would the nurse expect to observe?
- A. Pain relieved by pressure at McBurney's point.
- B. Rebound tenderness at McBurney's point.
- C. Pain in the left lower quadrant.
- D. Decreased bowel sounds in all quadrants.
Correct Answer: B
Rationale: rebound tenderness at McBurney's point is a classic sign of appendicitis
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The nurse knows which of the following is an important consideration in the care of a newborn with fetal alcohol syndrome?
- A. Prevent iron deficiency anemia.
- B. Decrease touch to prevent overstimulation.
- C. Provide feedings via gavage to decrease energy expenditure.
- D. Replace vitamins depleted as a result of poor maternal diet.
Correct Answer: D
Rationale: frequently, maternal diet is poor, and infant is malnourished; adequate intake of B complex vitamins is necessary for normal CNS function
The nurse is called to the room of a patient four days after abdominal surgery. The patient had been coughing and said he felt something give. The nurse observes that the edges of the incision have separated, and a small loop of the bowel protrudes through the incision. The nurse should position the patient
- A. with the head of the bed elevated 30°.
- B. with the foot of the bed tilted and the head of the bed down.
- C. with the head of the bed elevated 15°.
- D. with the head of the bed elevated 90°.
Correct Answer: C
Rationale: low Fowler's, reduces stress on suture line, may be placed supine with hips and knees bent
A patient is returned to his room following an appendectomy. The nurse notices a large amount of serosanguineous drainage on the dressing. It is MOST important for the nurse to obtain an answer to which of the following questions?
- A. Were there any intraoperative complications?
- B. Has the dressing been changed?
- C. Why didn't the recovery room nurse report any drainage?
- D. Was a tissue drain placed during surgery?
Correct Answer: D
Rationale: drain is frequently placed during surgery to prevent accumulation in wound, dressing should be reinforced
A client is scheduled for an intravenous pyelogram (IVP).
Nursing management prior to an intravenous pyelogram (IVP) would include which of the following?
- A. A fat-free meal the evening prior to the examination and radiopaque tablets at bedtime.
- B. Placement of a retention urinary catheter to facilitate dilation of the bladder sphincter.
- C. Cleansing enemas the evening before to provide for adequate visualization of the urinary tract.
- D. Explaining the importance of following directions regarding voiding during the Test .
Correct Answer: C
Rationale: Strategy: Answers are all implementations. Determine the outcome of each answer choice. Is it desired? (1) fat-free meal is associated with a gall bladder series (2) a retention Foley catheter may be in place, but not for the purpose of dilating the bladder sphincter (3) correct-because of the need to visualize the abdominal area, cleansing enemas the evening before an IVP are usually ordered (4) there are few directions the client needs to follow during the Test
The nurse is caring for a client who is postoperative day 1 after a total abdominal hysterectomy. Which of the following findings should the nurse report immediately?
- A. Temperature of 100.4°F (38°C).
- B. Mild incisional pain.
- C. Scant vaginal bleeding.
- D. Urine output of 50 mL/hour.
Correct Answer: A
Rationale: A temperature of 100.4°F suggests infection, a serious postoperative complication. Options B, C, and D are expected findings.