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The nurse is caring for a client who had an appendectomy 4 hours ago. Which finding requires immediate action by the nurse?
- A. Apical heart rate of 100 to 110 beats/minute.
- B. Redness and edema noted at the incision site.
- C. High-pitched sound heard upon inspiration.
- D. Pain rating of 8 on a scale of 1 to 10.
Correct Answer: C
Rationale: A high-pitched sound (stridor) indicates potential airway obstruction, a life-threatening emergency requiring immediate intervention to ensure airway patency.
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A client with sickle cell anemia develops a fever during the last hour of administration of a unit of packed red blood cells. When notifying the healthcare provider, which information should the nurse provide first using the SBAR (Situation, Background, Assessment, and Recommendation) communication process?
- A. Explain specific reason for urgent notification.
- B. Obtain a PRN prescription for acetaminophen for fever over 101° F (38.3° C).
- C. Preface the report by stating the client's name and admitting diagnosis.
- D. Communicate the pre-transfusion temperatures.
Correct Answer: C
Rationale: Per SBAR, starting with the client's name and diagnosis establishes identity and context, ensuring clear communication before detailing the situation, background, assessment, and recommendation.
After teaching a client newly diagnosed with cholecystitis about recommended diet changes, the nurse evaluates the client's learning. Which food choices eliminated by the client indicate to the nurse that teaching has been successful?
- A. Whole milk and daily servings of ice cream.
- B. Citrus fruit and melon with a salt substitute.
- C. Pasta with herbal butter and no meat sauce.
- D. Canned vegetables with additional table salt.
Correct Answer: A
Rationale: Eliminating whole milk and ice cream, which are high in fat, prevents gallbladder inflammation and gallstone formation, indicating successful learning about cholecystitis diet.
The nurse calls the healthcare provider because a client diagnosed with an abdominal aortic aneurysm (AAA) is reporting of low back pain. Which additional information about the client would be important for the nurse to tell the healthcare provider?
- A. White blood cell count and pulse rate.
- B. Hematocrit and blood pressure.
- C. Calcium level and skin condition.
- D. Serum amylase and level of consciousness.
Correct Answer: B
Rationale: Hematocrit and blood pressure are critical for AAA, as low hematocrit may indicate rupture or bleeding, and high blood pressure can exacerbate the aneurysm, necessitating urgent reporting.
The nurse is teaching a client with cancer about skin care for the portal site receiving external beam radiation. Which client action about skin care indicates a need for further teaching?
- A. Wears clothing to cover the radiation site.
- B. Washes the radiation site with antibacterial soap and water.
- C. Applies prescribed lotions to the radiation site.
- D. Dries the area with patting motions after taking a shower.
Correct Answer: B
Rationale: Washing with antibacterial soap can dry and irritate the sensitive skin at the radiation site, increasing the risk of damage. Mild, unscented soap is recommended, indicating a need for further teaching.
A client taking antibiotics for three days to treat a Streptococcal throat infection returns to the clinic reporting a feel itchy rash across the chest and arms. The nurse auscultates pulmonary wheezing and an elevated heart rate. Which action should the nurse implement?
- A. Swab the throat for a rapid strep test.
- B. Provide a mask for the client to wear.
- C. Instruct client to stop taking the antibiotics.
- D. Apply a hypoallergenic cream to the rash.
Correct Answer: C
Rationale: Symptoms like rash, wheezing, and tachycardia suggest an allergic reaction to antibiotics, requiring immediate cessation to prevent progression to severe reactions like anaphylaxis.