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The nurse is caring for a client who is postoperative day 1 after a laparoscopic cholecystectomy. 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. Right shoulder pain.
- D. Urine output of 40 mL/hour.
Correct Answer: A
Rationale: A temperature of 100.8°F suggests infection, a serious complication post-cholecystectomy requiring immediate evaluation. Options B, C, and D are expected: incision pain is normal, shoulder pain is from referred diaphragmatic irritation, and urine output 40 mL/hour is adequate.
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The nurse is teaching a client with a new diagnosis of type 2 diabetes about metformin (Glucophage). Which of the following instructions should the nurse include?
- A. Take the medication on an empty stomach.
- B. Report any nausea or diarrhea.
- C. Stop the medication if blood sugar is normal.
- D. Avoid regular kidney function Test s.
Correct Answer: B
Rationale: Nausea or diarrhea are common metformin side effects that may require dose adjustment, so reporting is important. Options A, C, and D are incorrect.
Two new admissions to the unit. One of the new admissions is diagnosed with pneumonia, and the other new patient is diagnosed with AIDS.
Which of the following assignments is MOST appropriate?
- A. Assign both patients to one room with one nurse caring for both patients.
- B. Place both patients in the same room and assign the care to different nurses.
- C. Assign each patient to a private rooms and assign both clients to one nurse.
- D. Place each client in a private room and assign each patient to a different nurse.
Correct Answer: D
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) increases the potential for transmission of infection (2) keeps the clients in the same room; should not be done (3) puts them in separate rooms but same nurse is caring for them (4) correct-to prevent spread of infection, clients should have private rooms with different nurses
The nurse is planning care for an 8 year-old child. Which of the following should be included in the plan of care?
- A. Encourage child to engage in activities in the playroom
- B. Promote independence in activities of daily living
- C. Talk with the child and allow him to express his opinions
- D. Provide frequent reassurance and cuddling
Correct Answer: A
Rationale: Encourage child to engage in activities in the playroom. According to Erikson, the school age child is in the stage of industry versus inferiority. To help them achieve industry, the nurse should encourage them to carry out tasks and activities in their room or in the playroom.
The nurse is preparing to administer a medication to a client via a nasogastric tube. Which of the following actions should the nurse perform FIRST?
- A. Check the placement of the nasogastric tube.
- B. Crush the medication and mix with water.
- C. Flush the tube with 30 mL of water.
- D. Position the client in a supine position.
Correct Answer: A
Rationale: Verifying nasogastric tube placement prevents aspiration, a priority before medication administration. Options B, C, and D follow placement confirmation.
A client admitted for regulation of her insulin dosage. The client takes 15 units of Humulin N insulin at 8 AM every day.
At 4 PM, which of the following nursing observations would indicate a complication from the insulin?
- A. Acetone odor to the breath, polyuria, and flushed skin.
- B. Irritability, tachycardia, and diaphoresis.
- C. Headache, nervousness, and polydipsia.
- D. Tenseness, tachycardia, and anorexia.
Correct Answer: B
Rationale: Strategy: Determine the cause of each symptom and how it relates to hypoglycemia. (1) signs of hyperglycemia (2) correct-Humulin N insulin is an intermediate-acting insulin that peaks from eight to twelve hours after administration; this is when signs and symptoms of hypoglycemia will occur (3) signs of hyperglycemia (4) signs of hyperglycemia