Nokea
The nurse is caring for a client post-laparoscopic cholecystectomy. Which discharge instruction is most important?
- A. Resume normal diet immediately
- B. Report fever or yellowing of skin
- C. Avoid bathing for 2 weeks
- D. Lift heavy objects as tolerated
Correct Answer: B
Rationale: Fever or jaundice post-cholecystectomy may indicate complications like infection or bile duct injury, requiring immediate reporting.
You may also like to solve these questions
The administration of an intramuscular injection to a neonate should be given in the:
- A. Gluteus maximus muscle.
- B. Vastus lateralis muscle.
- C. Deltoid muscle.
- D. The sternocleidomastoid muscle.
Correct Answer: B
Rationale: The vastus lateralis is the preferred site for IM injections in neonates due to its large muscle mass and minimal risk of nerve or bone injury.
A client with a diagnosis of rheumatoid arthritis is prescribed adalimumab (Humira). The nurse should monitor the client for which of the following side effects?
- A. Infection.
- B. Hypotension.
- C. Weight gain.
- D. Hyperglycemia.
Correct Answer: A
Rationale: Adalimumab, a TNF inhibitor, increases the risk of infections due to immune suppression.
The nurse has provided an in-service presentation to ancillary staff about standard precautions on the birthing unit. The nurse determines that one of the staff members needs further instructions when the nurse observes which of the following?
- A. Use of protective goggles during a cesarean delivery.
- B. Placement of bloody sheets in a container designated for contaminated linens.
- C. Wearing of sterile gloves to bathe a newly delivered neonate at 1 hour of age.
- D. Disposal of used scalpel blades in a puncture-resistant container.
Correct Answer: C
Rationale: Sterile gloves are unnecessary for bathing a neonate; clean gloves suffice, indicating a need for further instruction on standard precautions.
A 4-year-old is brought to the emergency department with sudden onset of a temperature of 103°F (39.5°C), sore throat, and refusal to drink. The child will not lie down and prefers to lean forward while sitting up. Which of the following should the nurse do next?
- A. Give 600 mg of acetaminophen (Tylenol) rectally, as ordered.
- B. Inspect the child's throat for redness and swelling.
- C. Have an appropriate-sized tracheostomy tube readily available.
- D. Obtain a specimen for a throat culture.
Correct Answer: C
Rationale: The symptoms suggest epiglottitis, a life-threatening condition requiring immediate airway management. Preparing a tracheostomy tube is the priority to ensure airway patency if obstruction occurs.
The most appropriate toys to give to a 5-month-old infant are:
- A. Plastic toy cars.
- B. Wooden puzzles.
- C. Stuffed animals.
- D. Soft, washable toys.
Correct Answer: D
Rationale: Soft, washable toys are safe and appropriate for a 5-month-old, who explores through touch and mouthing. Toy cars and puzzles are choking hazards, and stuffed animals may pose hygiene risks.