Nokea
The nurse is caring for a client who is postoperative day 1 after a cesarean section. Which of the following findings would be of GREATest concern to the nurse?
- A. Temperature of 100.8°F (38.2°C).
- B. Pain at the incision site.
- C. Lochia rubra with small clots.
- D. Urine output of 50 mL/hour.
Correct Answer: A
Rationale: A temperature of 100.8°F suggests infection, such as endometritis, a serious complication post-cesarean section requiring immediate evaluation. Options B, C, and D are expected: incision pain, lochia rubra, and urine output 50 mL/hour are normal on day 1.
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An eight-year-old with cystic fibrosis (CF).
Which of the following dietary requirements should be considered?
- A. High protein, high fat, and high calories.
- B. High protein, low fat, and high calories.
- C. Low protein, low fat, and low carbohydrate.
- D. High protein, high fat, and low carbohydrate.
Correct Answer: B
Rationale: Strategy: Think about each answer choice. (1) contains high fat (2) correct-impaired inTest inal absorption due to cystic fibrosis necessitates a diet higher in protein and calories; fat is decreased because it may interfere with absorption of other nutrients (3) not adequate for this child (4) contains high fat
The nurse believes a coworker is diverting narcotics. The nurse approaches the nurse manager to report the suspicions. Which of the following statements by the nurse is BEST?
- A. After my coworker has been on duty, the patients often need repeated doses of pain medication. I have seen her/him sleeping on duty three times.
- B. I saw my coworker downtown after work. S/he was acting really strange, like s/he didn't even recognize me.
- C. I think my coworker is stealing narcotics because s/he is always acting euphoric and seems high.
- D. I am sure my coworker is hanging around with drug dealers, and I think I saw tracks on her/his arms.
Correct Answer: A
Rationale: Objective observations, such as increased patient pain medication needs and sleeping on duty, provide verifiable evidence for investigation. Options B, C, and D are subjective or speculative, reducing their credibility.
The nurse is providing home care. Which assessment finding would suggest to the nurse that the elderly client should be evaluated for abuse?
- A. The client says, 'My daughter takes some of my Social Security money. She says it's to pay for my food and medicine.'
- B. The client has several bruises on her arms and legs.
- C. The client says her family is mean because they hire someone to stay with her when they go out.
- D. The client has several bruises and circular marks that look like cigarette burns on her back.
Correct Answer: D
Rationale: Bruises and circular marks resembling cigarette burns strongly suggest physical abuse, requiring immediate evaluation. Unexplained bruises are concerning but less specific, and the other options may reflect misunderstanding or caregiving arrangements.
The nurse is discussing negativity with the parents of a 30 month-old child. How should the nurse tell the parents to best respond to this behavior?
- A. Reprimand the child and give a 15 minute 'time out'
- B. Maintain a permissive attitude for this behavior
- C. Use patience and a sense of humor to deal with this behavior
- D. Assert authority over the child through limit setting
Correct Answer: C
Rationale: Use patience and a sense of humor to deal with this behavior. This approach supports the toddler’s developing autonomy.
A polydrug user has been in recovery for 8 months. The client has began skipping breakfast and not eating regular dinners. The client has also started frequenting bars to 'see old buddies.' The nurse understands that the client's behaviors are warning signs to indicate that the client may be
- A. Headed for relapse
- B. Feeling hopeless
- C. Approaching recovery
- D. In need of increased socialization
Correct Answer: A
Rationale: Headed for relapse. These behaviors suggest a return to risky environments and habits, indicating potential relapse.