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The nurse is caring for a client who is postoperative day 1 after a total hysterectomy. Which of the following findings would be of GREATest concern to the nurse?
- A. Temperature of 100.4°F (38°C).
- B. Pain at the incision site.
- C. Vaginal bleeding of 50 mL.
- D. Absence of bowel sounds.
Correct Answer: A
Rationale: A temperature of 100.4°F suggests infection, a serious complication post-hysterectomy requiring immediate evaluation. Options B, C, and D are expected: incision pain, minimal vaginal bleeding, and absent bowel sounds are normal on day 1.
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After abdominal surgery, a client is admitted from the recovery room with intravenous fluid infusing at 100 cc/h. One hour later, the nurse finds the clamp wide open and notes that the client has received 850 cc.
The nurse would be MOST concerned by which of the following?
- A. A CVP reading of 12 and bradycardia.
- B. Tachycardia and hypotension.
- C. Dyspnea and oliguria.
- D. Rales and tachycardia.
Correct Answer: D
Rationale: Strategy: 'MOST concerned' indicates a complication. (1) CVP is normal, and bradycardia is incorrect (2) does not contain information relevant to fluid overload (3) does not contain information relevant to fluid overload (4) correct-indicate cardiovascular fluid overload
A woman is admitted to the labor and delivery unit in a sickle cell crisis.
- A. Which nursing action is the highest priority for a woman in labor with a sickle cell crisis?
- B. Administer oxygen.
- C. Turn her to the right side.
- D. Provide adequate hydration.
- E. Start antibiotics.
Correct Answer: C
Rationale: Adequate hydration is the highest priority in sickle cell crisis to prevent further sickling of red blood cells and improve blood flow, reducing the risk of complications. Oxygen, repositioning, and antibiotics may be supportive but are not the primary intervention.
A client has a nasogastric tube in place after extensive abdominal surgery. The client complains of nausea. His abdomen is distended, and there are no bowel sounds.
The FIRST nursing action should be to
- A. administer the PRN pain medication and an antiemetic.
- B. irrigate the nasogastric tube with normal saline.
- C. determine if the nasogastric tube is patent and draining.
- D. check the placement of the nasogastric tube by auscultation.
Correct Answer: C
Rationale: Strategy: Answers are a mix of assessments and implementations. Is this a situation that requires assessment? Yes. (1) implementation, may be carried out after the patency of the tube is determined (2) implementation, patency should be checked first (3) correct-should first assess if the tube is open and draining to determine if there is a problem with the nasogastric tube; if it is patent and draining it does not need to be irrigated (4) assessment, patency should be checked first by aspirating stomach contents, not by auscultation
The nurse is caring for a client with a suspected myocardial infarction. Which of the following actions should the nurse perform FIRST?
- A. Administer aspirin 325 mg PO.
- B. Apply oxygen at 2 L/min via nasal cannula.
- C. Obtain a 12-lead ECG.
- D. Start an IV line.
Correct Answer: B
Rationale: Applying oxygen is the priority to improve myocardial oxygenation in a suspected myocardial infarction, addressing the immediate threat of hypoxia. Options A, C, and D are important but secondary: aspirin prevents clot progression, ECG confirms diagnosis, and IV access supports medication delivery.
An 18-year-old client with anorexia nervosa is admitted to the hospital.
In planning to care for the client, the nurse would expect the client to
- A. view her appearance as 'skinny.'
- B. be hypoactive and withdrawn.
- C. want to talk about and plan her meals.
- D. have a close relationship with her mother.
Correct Answer: C
Rationale: Strategy: Determine how each answer choice relates to anorexia. (1) usually view their appearance as fat (2) inaccurate for client with anorexia nervosa (3) correct-display a marked preoccupation with food (4) inaccurate for client with anorexia nervosa