Nokea
The nurse is caring for a client who is 6 hours postoperative after an appendectomy. Which of the following findings would be of GREATest concern to the nurse?
- A. Heart rate of 88 bpm.
- B. Temperature of 100.8°F (38.2°C).
- C. Absence of bowel sounds.
- D. Pain rated as 6 out of 10.
Correct Answer: B
Rationale: A temperature of 100.8°F 6 hours post-appendectomy suggests infection, possibly from perforation or abscess, requiring immediate evaluation. Options A, C, and D are expected: heart rate 88 is normal, absent bowel sounds are typical post-surgery, and moderate pain is common.
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As a client is being discharged following resolution of a spontaneous pneumothorax, he tells the nurse that he is now going to Hawaii for a vacation. The nurse would warn him to avoid
- A. Surfing
- B. Scuba diving
- C. Parasailing
- D. Swimming
Correct Answer: B
Rationale: Scuba diving. The nurse would strongly emphasize the need for clients with history of spontaneous pneumothorax problems to avoid high altitudes, flying in unpressurized aircraft and scuba diving. The negative pressures could cause the lung to collapse again.
The nurse is caring for a man who has severe burns and had a skin graft. What nursing care measure is appropriate at the graft site the day of the graft?
- A. Leave the graft site open to the air.
- B. Elevate the recipient site.
- C. Encourage range-of-motion exercises.
- D. Change the dressing twice a day.
Correct Answer: B
Rationale: Elevating the graft site reduces edema, promoting graft adherence on the first day. Open exposure, exercises, or frequent dressing changes risk graft failure.
A male client is preparing for discharge following an acute myocardial infarction. He asks the nurse about his sexual activity once he is home. What would be the nurse's initial response?
- A. Give him written material from the American Heart Association about sexual activity with heart disease
- B. Answer his questions accurately in a private environment
- C. Schedule a private, uninterrupted teaching session with both the client and his wife
- D. Assess the client's knowledge about his health problems
Correct Answer: D
Rationale: The nursing process is continuous and cyclical in nature. When a client expresses a specific concern, the nurse performs a focused assessment to gather additional data prior to planning and implementing nursing interventions.
A client is admitted with irritable bowel syndrome.
The nurse would anticipate the client's history to reflect which of the following?
- A. Pattern of alternating diarrhea and constipation.
- B. Chronic diarrhea stools occurring 10-12 times per day.
- C. Diarrhea and vomiting with severe abdominal distention.
- D. Bloody stools with increased cramping after eating.
Correct Answer: A
Rationale: Strategy: Think about each answer choice. (1) correct-condition is often called spastic bowel disease; no inflammation is present (2) refers to inflammatory bowel disease such as ulcerative colitis or Crohn's disease (3) refers to inflammatory bowel disease such as ulcerative colitis or Crohn's disease (4) bloody stools do not occur
A client receiving oxygen at 6 L/min.
What information concerning the patient is MOST important for the nurse to document on the lab slip that accompanies the blood sample?
- A. The patient's position in bed and the respiratory rate.
- B. The site used to obtain the blood specimen.
- C. The use of supplemental oxygen.
- D. The patient's diagnosis and blood type.
Correct Answer: C
Rationale: Strategy: Think about each answer choice and how it relates to blood gases. (1) unnecessary to document positioning (2) unnecessary to document site used (3) correct-necessary for accurate Test results (4) unnecessary to document blood type, should document diagnosis