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The nurse is caring for a client who is postoperative day 1 after a prostatectomy. 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. Urinary output of 200 mL/hour.
- D. Blood-tinged urine.
Correct Answer: A
Rationale: A temperature of 100.8°F suggests infection, a serious complication post-prostatectomy requiring immediate evaluation. Options B, C, and D are expected: incision pain, high urinary output, and blood-tinged urine are normal on day 1.
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Which of the following is a correctly stated nursing diagnosis for a client with abruptio placentae?
- A. Infection related to obstetrical trauma.
- B. Potential for fetal injury related to abruptio placentae.
- C. Potential alteration in tissue perfusion related to depletion of fibrinogen.
- D. Fluid volume deficit related to bleeding.
Correct Answer: D
Rationale: Abruptio placentae causes hemorrhage, leading to fluid volume deficit, a major nursing concern. The other options are incorrectly stated or irrelevant: infection is not typical, ‘potential’ diagnoses are not standard, and fibrinogen depletion is not the primary issue.
The nurse is caring for a client with chronic kidney disease who is receiving epoetin alfa (Epogen). Which of the following laboratory results should the nurse report immediately?
- A. Hemoglobin 14 g/dL.
- B. Potassium 4.5 mEq/L.
- C. Creatinine 3.0 mg/dL.
- D. Calcium 9.0 mg/dL.
Correct Answer: A
Rationale: A hemoglobin of 14 g/dL is too high, risking hypertension or thrombosis with epoetin alfa. Options B, C, and D are expected or normal.
A client with a temperature of 103°F (39.4°C).
Body compensatory mechanisms would include which of the following?
- A. Decreased respiratory rate and bradycardia.
- B. Normal blood pressure and pulse.
- C. Increased respiratory rate and tachycardia.
- D. Diaphoresis with cool, clammy skin.
Correct Answer: C
Rationale: Strategy: Think about each answer choice. (1) respirations and heart rate will increase with fever (2) blood pressure and pulse usually increase with fever (3) correct-hyperthermia increases the oxygen requirements, which results in faster breathing as well as an increase in the pulse rate (4) diaphoresis may occur, but the skin will be warm
A nurse is caring for a 2 year-old child after corrective surgery for Tetralogy of Fallot. The mother reports that the child has suddenly begun seizing. The nurse recognizes this problem is probably due to
- A. A cerebral vascular accident
- B. Postoperative meningitis
- C. Medication reaction
- D. Metabolic alkalosis
Correct Answer: A
Rationale: A cerebral vascular accident. Polycythemia occurs as a physiological reaction to chronic hypoxemia, increasing the risk of thromboembolic events like cerebrovascular accidents, which can manifest as seizures.
A client hospitalized with a fractured mandible is to be discharged. Which piece of equipment should be kept on the client with a fractured mandible?
- A. Wire cutters
- B. Oral airway
- C. Pliers
- D. Tracheostomy set
Correct Answer: A
Rationale: Wire cutters are essential for a fractured mandible with wiring, in case of emergency airway obstruction. Oral airway , pliers , and tracheostomy set are not standard.