Nokea
The nurse is caring for a client who is postoperative day 1 after a total hysterectomy. 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. Scant vaginal bleeding.
- D. Urine output of 50 mL/hour.
Correct Answer: B
Rationale: A temperature of 100.8°F suggests infection, a serious post-hysterectomy complication. Options A, C, and D are normal.
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A client comes to the emergency room with complaints of 'numbness, tingling, and coldness' of her left leg. She is able to walk. You note that the skin appears pale and is cool to the touch. What should the nurse do first?
- A. Ask if she had had a similar condition in her arms or the other leg
- B. Notify the physician immediately
- C. Obtain a detailed nursing health history
- D. Palpate and record the femoral, popliteal, posterior tibial, and dorsalis pedis pulses in the affected leg
Correct Answer: D
Rationale: Palpating pulses assesses for arterial occlusion, the priority to determine the cause of numbness and coldness, guiding urgent intervention.
The nurse is to obtain pedal pulses on a client following a cardiac catheterization. Which is the proper procedure?
- A. Place the fingertips against the wrist bone.
- B. Place the stethoscope over the apex of the heart.
- C. Place the fingertips against the side of the neck.
- D. Place the fingertips on top of the foot.
Correct Answer: D
Rationale: Pedal pulses are assessed by palpating the dorsalis pedis or posterior tibial arteries on the foot, checking for circulation post-catheterization.
The nurse is caring for a six-year-old boy several hours after the application of a hip spica cast.
- A. What should the nurse do first for a six-year-old complaining of pain in his left foot several hours after hip spica cast application?
- B. Elevate the left leg on two pillows.
- C. Palpate the cast for warmth and wetness.
- D. Administer pain medication as ordered.
- E. Check the blanching sign on both feet.
Correct Answer: D
Rationale: Pain in the foot post-cast application suggests possible circulatory impairment. Checking the blanching sign (capillary refill) assesses circulation, comparing the affected and unaffected sides. Elevation, palpation, or medication may follow but do not address the urgent need to assess circulation.
A one-year-old child.
While doing a physical examination of a one-year-old child, which of the following assessments should be done by the nurse LAST?
- A. Take a rectal temperature.
- B. Auscultate the breath sounds.
- C. Auscultate the apical heart rate.
- D. Evaluate motor functions.
Correct Answer: A
Rationale: Strategy: Picture the situation. (1) correct-all invasive procedures should be done last, so as not to alter cardiopulmonary assessment of the child (2) should be done before a rectal temperature (3) should be done before a rectal temperature (4) should be done before a rectal temperature
The nurse is teaching a client with a new diagnosis of type 2 diabetes about metformin (Glucophage). Which of the following instructions should the nurse include?
- A. Take the medication on an empty stomach.
- B. Report any nausea or diarrhea.
- C. Stop the medication if blood sugar is normal.
- D. Avoid regular kidney function Test s.
Correct Answer: B
Rationale: Nausea or diarrhea are common metformin side effects that may require dose adjustment, so reporting is important. Options A, C, and D are incorrect.