Nokea
The nurse is caring for a client who is postoperative day 1 after a prostatectomy. Which of the following findings should the nurse report immediately?
- A. Mild pain at the incision site.
- B. Temperature of 100.8°F (38.2°C).
- C. Blood-tinged urine.
- D. Urine output of 200 mL/hour.
Correct Answer: B
Rationale: A temperature of 100.8°F suggests infection, a serious post-prostatectomy complication. Options A, C, and D are normal.
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The client asks the nurse how the health care provider could tell she was pregnant 'just by looking inside.' What is the best explanation by the nurse?
- A. Bluish coloration of the cervix and vaginal walls
- B. Pronounced softening of the cervix
- C. Clot of very thick mucous that obstructs the cervical canal
- D. Slight rotation of the uterus to the right
Correct Answer: A
Rationale: Chadwick's sign is a bluish-purple coloration of the cervix and vaginal walls, occurring at 4 weeks of pregnancy, that is caused by vasocongestion.
A 6-year-old child is seen in the physician's office. His mother tells you that for the last few weeks, the child has been urinating frequently, drinking and eating a lot. The nurse determines that the urine specific gravity is 1.004. The child is afebrile. What tests does the nurse expect to be ordered for this client at this time?
- A. CBC with differential
- B. Urine and finger stick glucose tests
- C. Intravenous pyelogram.
- D. Urine for culture and sensitivity
Correct Answer: B
Rationale: Polyuria, polydipsia, polyphagia, and low urine specific gravity (1.004) suggest diabetes mellitus; urine and finger stick glucose tests confirm hyperglycemia. CBC, IVP, or culture are less relevant.
During the development of a nursing care plan, the nurse should consider which of the following clients for the use of a restraint?
- A. An infant with septicemia.
- B. A child with a tonsillectomy.
- C. An infant with cleft lip repair.
- D. A child with meningitis.
Correct Answer: C
Rationale: arm restraints are necessary to prevent infant from rubbing or otherwise disturbing suture line
An infant is admitted for vomiting and diarrhea. The infant's anterior fontanelle is depressed, and he has a fever of 103.2°F (39.5°C).
Which of the following nursing actions would be MOST appropriate?
- A. Determine daily weights and evaluate weight loss.
- B. Evaluate infant's ability to take in fluids.
- C. Place a full bottle of Pedi-Lyte at the bedside.
- D. Start an intravenous infusion.
Correct Answer: B
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Is there an appropriate assessment? Yes. (1) assessment, correct information, but is not what the question asks for (2) correct-assessment, will assist in determining if hydration can be done through oral fluids alone (3) implementation, does not do anything to improve the situation; placing a full bottle at the bedside doesn't guarantee that the infant is taking fluids (4) implementation, would be implemented later
A prenatal client tests positive for chlamydia in her ninth month. She asks why she should be treated since she does not have symptoms. The nurse should tell the client that if she is not treated before delivery, there is a risk of which problem?
- A. Transplacental infection of the fetus
- B. Neonatal ophthalmia
- C. Pregnancy-induced hypertension
- D. Congenital anomalies
Correct Answer: B
Rationale: Untreated chlamydia can cause neonatal conjunctivitis (ophthalmia neonatorum) during vaginal delivery, necessitating treatment to prevent infant complications.