Nokea
The nurse is caring for a client who is postoperative day 1 after a total hip replacement. 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. Leg swelling on the operative side.
- D. Urine output of 40 mL/hour.
Correct Answer: A
Rationale: A temperature of 100.8°F suggests infection, a serious complication post-hip replacement requiring immediate evaluation. Options B, C, and D are expected or less concerning: incision pain and leg swelling are normal, and urine output 40 mL/hour is adequate.
You may also like to solve these questions
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.
An HIV-positive infant to receive an oral polio immunization.
Which of the following nursing actions is MOST appropriate?
- A. Wear gloves and a gown when administering the immunization.
- B. Administer the immunization as the infant is being discharged.
- C. Call the physician and discuss the rationale for the immunization.
- D. Administer the medication in the same manner as you would to any other infant.
Correct Answer: C
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) does not address the identified problem of the compromised immune system (2) does not address the identified problem of the compromised immune system (3) correct-polio vaccine contains live virus and should not be given to children who are immunocompromised (4) does not address the identified problem of the compromised immune system
A client with suspected Addison's disease is scheduled for a rapid corticotrophin stimulation test. Which of the following will the nurse include in her teaching?
- A. The need to limit fluid intake
- B. The need for periodic blood samples
- C. The need for collection of a 24-hour urine
- D. The need for frequent IV injections
Correct Answer: B
Rationale: The rapid corticotrophin stimulation test requires periodic blood samples to measure cortisol levels before and after ACTH administration.
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.
An adult who has just been diagnosed with pulmonary tuberculosis asks the nurse how long he will have to be in isolation. What should be included in the nurse's reply?
- A. Isolation is for the duration of the treatment, which is at least 26 weeks.
- B. Isolation is necessary as long as the client has a cough.
- C. When the client has three negative sputum specimens, isolation is discontinued.
- D. When the evening fevers and night sweats subside, isolation is discontinued.
Correct Answer: C
Rationale: Isolation for pulmonary TB ends when three consecutive sputum samples are negative, indicating non-infectiousness, typically before the full 6-month treatment.