Nokea
The nurse is caring for a client who is postoperative day 1 after a nephrectomy. 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. Urine output of 30 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-nephrectomy requiring immediate evaluation. Options B, C, and D are expected or normal: incision pain is typical, urine output 30 mL/hour is adequate for one kidney, and blood pressure 130/80 mmHg is stable.
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Immediately after surgery the client with an above-the-knee amputation of the right leg refuses to look at the operative site. The most immediate diagnosis that can be made is:
- A. Self-care deficit
- B. Potential for infection
- C. Disturbance in self-concept
- D. Cognitive deficit
Correct Answer: C
Rationale: Refusing to look at the operative site suggests a disturbance in self-concept, as the client may be struggling with acceptance of the altered body image post-amputation.
The nurse is teaching a client with a new diagnosis of hyperthyroidism about propylthiouracil (PTU). Which of the following statements by the client indicates a need for further teaching?
- A. I should report a fever to my doctor.
- B. I should take this medication with food.
- C. I should avoid eating shellfish.
- D. I should stop this medication if my thyroid levels are normal.
Correct Answer: D
Rationale: Stopping propylthiouracil when thyroid levels are normal is incorrect, as hyperthyroidism requires prolonged treatment to maintain euthyroid status. Options A, B, and C are correct: fever may indicate agranulocytosis, food reduces GI upset, and shellfish (iodine-rich) should be avoided.
A man who has diabetes complains of hunger; is pale, shaky, and perspiring; and has cool skin. What is the most appropriate initial action for the nurse?
- A. Call the physician for orders
- B. Give the client cola to drink
- C. Have the client lie down
- D. Administer the next dose of insulin
Correct Answer: B
Rationale: Symptoms indicate hypoglycemia; giving cola provides quick glucose to raise blood sugar. Calling the physician, lying down, or giving insulin delays or worsens the situation.
The nurse is at the community center speaking with retired people about glaucoma. Which comment by one of the retirees would the nurse support to reinforce correct information?
- A. I usually avoid driving at night since lights sometimes seem to make things blur.'
- B. I take half of the usual dose for my sinuses to maintain my blood pressure.'
- C. I have to sit at the side of the pool with the grandchildren since I can't swim with this eye problem.'
- D. I take extra fiber and drink lots of water to avoid getting constipated.'
Correct Answer: D
Rationale: I take extra fiber and drink lots of water to avoid getting constipated.' Any activity that involves straining should be avoided in clients with glaucoma. Such activities would increase intraocular pressure.
A client with a diagnosis of Methicillin resistant Staphylococcus aureus (MRSA) has died. Which type of precautions is appropriate to use when performing postmortem care?
- A. Airborne precautions
- B. Droplet precautions
- C. Contact precautions
- D. Compromised host precautions
Correct Answer: C
Rationale: The resistant bacteria remain alive for up to 3 days after the client dies. Therefore, contact precautions must still be implemented.