Nokea
The nurse is caring for a child immediately post-operative following a tonsillectomy. Which assessment finding requires immediate follow-up?
- A. Discomfort while speaking
- B. Frequent swallowing
- C. Drowsiness
- D. Pain with occasional coughing
Correct Answer: B
Rationale: Frequent swallowing in a post-tonsillectomy child may indicate bleeding in the throat, as the child swallows blood, requiring immediate follow-up to prevent hemorrhage. Discomfort, drowsiness, and pain with coughing are expected findings and less urgent.
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The nurse plans care for a client immediately post-operative. The nurse should initially assess the client's
- A. respiratory status
- B. tolerance to by-mouth (PO) fluids
- C. pain level
- D. ability to move the extremities
Correct Answer: A
Rationale: Respiratory status is the priority assessment post-operatively to ensure airway patency and adequate oxygenation, following the ABCs (airway, breathing, circulation) of care. Pain, fluid tolerance, and extremity movement are important but secondary to ensuring respiratory stability.
The nurse is performing an assessment on a client. Which of the following findings would support a diagnosis of peripheral neuropathy in the lower extremities?
- A. Abnormal gait
- B. Absent or decreased pulses
- C. Swelling around the ankles
- D. Decreased hair growth
Correct Answer: A
Rationale: Abnormal gait is a hallmark of peripheral neuropathy due to sensory or motor deficits. Absent pulses indicate vascular issues, swelling suggests edema, and decreased hair growth is non-specific.
The infection control nurse is conducting rounds on the nursing unit and should ensure which conditions are isolated with contact precautions? Select all that apply.
- A. Hepatitis C
- B. Cryptococcal meningitis
- C. Clostridium difficile
- D. Scabies
- E. Rheumatic fever
- F. Botulism
- G. Hepatitis B
Correct Answer: C,D
Rationale: Clostridium difficile and scabies require contact precautions due to direct or indirect transmission. Others require standard precautions.
The nurse is preparing to remove an intrajugular central venous catheter. It would be appropriate to place the client in which position for this procedure?
- A. Reverse Trendelenburg
- B. Left lateral
- C. Trendelenburg
- D. High-Fowler's
Correct Answer: C
Rationale: Trendelenburg position (head down) reduces the risk of air embolism during intrajugular catheter removal by increasing venous pressure. Other positions do not minimize this risk effectively.
The nurse is ambulating a client who is wearing a gait belt. The client begins to fall. The nurse should take which appropriate action to minimize injury?
- A. Hold the gait belt, extend one leg, let the client slide against the leg, and lower the client to the floor.
- B. Let go of the gait belt, grab the client under each arm, and gently lower the client to the floor.
- C. Grasp the gait belt, and instruct the client to fall gently down to the floor in a side-lying position.
- D. Hold the gait belt, and lower the client to the floor by using a narrow base of support.
Correct Answer: A
Rationale: Using the gait belt to guide the client against the nurse’s leg minimizes injury. Letting go, instructing a side-lying fall, or using a narrow base increases risk.