Nokea
The nurse is caring for a client who had a cholecystectomy. Which of the following observations is MOST important for the nurse to report to the next shift?
- A. Resting after receiving IM pain medication.
- B. No bowel sounds present.
- C. IV infusing at 100 cc/h.
- D. Breath sounds decreased in both lower lobes.
Correct Answer: D
Rationale: Decreased breath sounds suggest atelectasis or pneumonia, serious post-cholecystectomy complications due to reduced ventilation from pain. Options A, B, and C are routine: resting is expected, absent bowel sounds are normal post-surgery, and IV rate is standard.
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The nurse plans care for a 36-year-old woman with Graves' disease. The nurse knows that which of the following foods or fluids should be restricted for this client?
- A. Milk.
- B. Apples.
- C. Orange juice.
- D. Tea.
Correct Answer: D
Rationale: Tea contains caffeine, which can exacerbate hyperthyroidism symptoms like tachycardia in Graves’ disease. Options A, B, and C are not contraindicated.
A 3 year-old child diagnosed as having celiac disease attends a day care center. Which of the following would be an appropriate snack?
- A. Cheese crackers
- B. Peanut butter sandwich
- C. Potato chips
- D. Vanilla cookies
Correct Answer: C
Rationale: Children with celiac disease should eat a gluten free diet. Potato chips are naturally gluten-free, unlike the other options which contain wheat-based ingredients.
A 23-year-old man comes to the AIDS clinic for treatment of large, painful, purplish-brown open areas on his right arm and back.
The nurse should instruct the client to
- A. clean the area carefully with soap and warm water every day and cover them with a sterile dressing.
- B. soak in a warm tub twice a day and rub the areas with a washcloth before covering them.
- C. shower daily using a mild antimicrobial soap from a pump dispenser and leave the lesions uncovered.
- D. clean the lesions twice a day with a diluted solution of povidone-iodine (Betadine) and leave them open to the air.
Correct Answer: A
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-open Kaposi's sarcoma lesions should be cleaned and dressed daily to prevent secondary infection (2) not done because of risk of secondary skin infection (3) important to keep the skin clean to prevent secondary skin infection but should be covered due to open areas (4) treatment for herpes simplex virus abscess, not Kaposi's sarcoma
A client is admitted with suspected fracture of the left hip. The most consistent finding in the client with the hip fracture is:
- A. Pain in the hip and affected leg
- B. Absence of pedal pulses
- C. Disalignment of the leg
- D. Diminished sensation
Correct Answer: C
Rationale: Disalignment of the leg , such as shortening or external rotation, is the most consistent sign of a hip fracture. Pain is common but less specific. Pulses and sensation are typically intact.
A preschool client's mother reports that the child has frequent bouts of gastroenteritis.
It would be MOST important for the nurse to ask which of the following questions?
- A. Are there other children in the family?'
- B. Does the child attend a day care center?'
- C. Does the child play with neighborhood children?'
- D. Is the child current on his immunizations?'
Correct Answer: B
Rationale: Strategy: Determine why the nurse would make the assessment and how it relates to gastroenteritis. (1) does not pose a problem or solution regarding gastroenteritis (2) correct-environments with increased numbers of children (day care) more likely to promote infections due to close living conditions and increased likelihood of disease transmission (3) possible source of infection, but not as likely as a day care center (4) does not pose a problem or solution regarding gastroenteritis