Nokea
The nurse is caring for a client who has had spinal fusion, with insertion of hardware. The nurse would be most concerned with which assessment finding?
- A. Temperature of 101.6°F (38.7°C) orally
- B. Complaints of discomfort during repositioning
- C. Old bloody drainage outlined on the surgical dressing
- D. Discomfort during coughing and deep-breathing exercises
Correct Answer: A
Rationale: A fever of 101.6°F suggests a possible postoperative infection, a serious complication after spinal fusion with hardware, requiring immediate attention.
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The client with viral skin lesions is experiencing pruritus. Which statement would be an appropriate long-term goal?
- A. The client will refrain from scratching the skin.
- B. The client will maintain intact skin integrity.
- C. The client will have relief from itching.
- D. The client will not develop a secondary bacterial infection.
Correct Answer: B
Rationale: Maintaining intact skin integrity is a key long-term goal for managing pruritus and preventing complications like infections.
During an assessment the nurse notes skin changes on the patient's elbows and knees. Which findings support that these changes are plaque psoriasis?
- A. Red raised areas with inconsistent borders
- B. Thick red plaques covered with silvery scales
- C. Large reddened areas of weeping and maceration
- D. Small raised and reddened areas with fluid-filled pustules
Correct Answer: B
Rationale: Plaque psoriasis typically presents as thick red plaques with silvery scales, especially on extensor surfaces like elbows and knees, distinguishing it from other descriptions.
The parents of a 2-year-old child diagnosed with measles call the pediatric clinic about the child being uncomfortable, irritable, and fretful. Which recommendation should the nurse discuss?
- A. Alternate ibuprofen with children's aspirin every 4 hours.
- B. Apply diphenhydramine cream to the rash.
- C. Administer acetaminophen elixir to the child.
- D. Tell the parents that there is no medication for the child.
Correct Answer: C
Rationale: Acetaminophen reduces discomfort in measles. Aspirin risks Reye's syndrome, diphenhydramine cream isn't suitable, and denying medication ignores symptom relief options.
Which laboratory value should be monitored by the nurse for the client diagnosed with diabetes insipidus?
- A. Serum sodium
- B. Serum calcium
- C. Urine glucose
- D. Urine white blood cells
Correct Answer: A
Rationale: Diabetes insipidus causes dilute urine and hypernatremia; serum sodium monitoring is key.
The nurse notes that a patient's fingertips are blue in color. What should this finding indicate to the nurse?
- A. Anemia
- B. Liver disease
- C. Hemosiderin
- D. Poor perfusion
Correct Answer: D
Rationale: Cyanosis (blue discoloration) indicates poor perfusion or inadequate oxygenation of blood.