Nokea
The nurse is caring for a client who is postoperative day 1 after a mitral valve replacement. Which of the following findings would be of GREATest concern to the nurse?
- A. Temperature of 100.8°F (38.2°C).
- B. Heart rate of 90 bpm.
- C. Chest tube drainage of 100 mL/hour.
- D. Blood pressure of 130/80 mmHg.
Correct Answer: A
Rationale: A temperature of 100.8°F suggests infection, a serious complication post-valve replacement due to risk of endocarditis, requiring immediate evaluation. Options B, C, and D are expected or normal: heart rate 90 bpm, drainage 100 mL/hour, and blood pressure 130/80 mmHg are stable.
You may also like to solve these questions
The nurse is caring for a client with a history of rheumatoid arthritis who is receiving prednisone 10 mg PO daily. Which of the following client statements would be of GREATest concern to the nurse?
- A. I have a headache sometimes.
- B. I feel tired in the afternoon.
- C. I have gained 5 pounds this month.
- D. I take my medication with food.
Correct Answer: C
Rationale: Weight gain of 5 pounds in a month suggests a side effect of prednisone, such as fluid retention or increased appetite, requiring evaluation to prevent complications like hypertension. Options A, B, and D are less concerning: headaches and fatigue are nonspecific, and taking with food is appropriate.
In planning care for a 6 month-old infant, what must the nurse provide to assist in the development of trust?
- A. Food
- B. Warmth
- C. Security
- D. Comfort
Correct Answer: C
Rationale: Security. Providing consistent, loving care fosters trust, a key developmental need for infants per Erikson's theory.
The nurse is caring for clients in a rehabilitation facility. The nursing team reports that a client recovering from a hip fracture has repeatedly 'transferred herself to the floor.' Which of the following actions, if taken by the nurse, is BEST?
- A. Place the call light within the client's reach.
- B. Remove the footrests from the wheelchair.
- C. Observe the client trying to rise from a sitting to a standing position.
- D. Place a posey vest restraint on the client.
Correct Answer: C
Rationale: Observing the client’s transfer technique identifies the cause of falls, guiding interventions. Options A, B, and D are premature or restrictive.
A child is admitted in sickle cell crisis. Which factor in the child's history is most likely related to the onset of the crisis?
- A. The child just completed final exams at school.
- B. The child ran a marathon yesterday.
- C. The child recently had a cold.
- D. The child received a hepatitis A immunization two weeks ago.
Correct Answer: C
Rationale: Infections, like a recent cold, can trigger sickle cell crisis by increasing oxygen demand and causing dehydration, leading to sickling of red blood cells.
The nurse is to administer Lanoxin(digoxin) elixir to a 6-month old with a congenital heart defect. The nurse auscultates an apical pulse rate of 100 . The nurse should:
- A. Record the heart rate and call the physician.
- B. Record the heart rate and administer the medication.
- C. Administer the medication and recheck the heart rate in 15 minutes.
- D. Hold the medication and recheck the heart rate in 30 minutes.
Correct Answer: B
Rationale: A pulse of 100 in a 6-month-old is normal (80-150 bpm), so the nurse should administer digoxin . Calling the physician or holding the dose is unnecessary. Rechecking later is not standard.