Nokea
The nurse is caring for a client who is postoperative day 1 after a total abdominal hysterectomy. Which of the following findings should the nurse report immediately?
- A. Temperature of 100.4°F (38°C).
- B. Mild incisional pain.
- C. Scant vaginal bleeding.
- D. Urine output of 50 mL/hour.
Correct Answer: A
Rationale: A temperature of 100.4°F suggests infection, a serious postoperative complication. Options B, C, and D are expected findings.
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The nurse is performing an ice massage for a client in chronic pain. The nurse is MOST concerned if which of the following is observed?
- A. Redness or inflammation of the tissue.
- B. Mottling or graying of the tissue.
- C. The client states that she feels a burning and tingling sensation in the area.
- D. The client states that she feels a numbness and a cold sensation in the area.
Correct Answer: B
Rationale: Mottling or graying indicates potential frostbite or tissue damage, a serious concern requiring immediate cessation of ice massage. Options A, C, and D are less critical: redness is common, burning/tingling suggests ischemia, and numbness/cold is expected.
An elderly man is admitted to an inpatient psychiatric unit with an initial diagnosis of psychotic depression. The INITIAL nursing priority is to
- A. clarify perceptual distortions.
- B. establish reality orientation.
- C. ensure client and milieu safety.
- D. increase self-esteem.
Correct Answer: C
Rationale: initial nursing priority for all psychiatric patients is to ensure their safety and the safety of all members of the milieu
The nurse is caring for a client with a history of congestive heart failure (CHF). Which of the following findings would indicate to the nurse that the client's condition is worsening?
- A. Clear lung sounds bilaterally.
- B. Weight gain of 2 pounds in 24 hours.
- C. Urine output of 1,200 mL in 24 hours.
- D. Heart rate of 88 beats per minute.
Correct Answer: B
Rationale: weight gain is a sign of fluid retention, indicating worsening CHF
A 20-year-old woman calls the outpatient clinic to schedule her first Papanicolaou's smear. The nurse should instruct the client to
- A. avoid intercourse for 48 hours before the examination.
- B. avoid douching for 24 hours prior to her appointment.
- C. withhold all foods and fluids 12 hours before the appointment.
- D. save her first voided urine specimen the morning of her appointment.
Correct Answer: B
Rationale: douching would affect appearance of cells in vaginal smear, would make test inaccurate
The nurse is preparing to begin a dopamine (Intropin) infusion on a client.
Before beginning the infusion the nurse should
- A. evaluate the urine output.
- B. obtain the client's weight.
- C. determine the patency of the IV line.
- D. measure pulmonary artery pressures.
Correct Answer: C
Rationale: Strategy: Determine how each answer choice relates to dopamine. (1) not a critical assessment at this time (2) contains correct information, but is not a priority (3) correct-if extravasation occurs, there is sloughing of the surrounding skin and tissue; patent IV line is essential to prevent serious side effects (4) not a critical assessment at this time