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The nurse is caring for a client who is postoperative day 2 following a cholecystectomy. The client reports nausea and has not had a bowel movement since surgery. Which of the following actions should the nurse take FIRST?
- A. Administer an antiemetic as ordered.
- B. Encourage ambulation.
- C. Notify the physician.
- D. Assess the client’s abdomen for bowel sounds.
Correct Answer: D
Rationale: assessment of bowel sounds is the first step to determine if there is a postoperative ileus or other complication
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The nurse is assessing the laboratory results of a client scheduled to receive phenytoin (Dilantin). The Dilantin level, drawn 2 hours ago, is 30 mcg/mL. What is the appropriate nursing action?
- A. Administer the Dilantin as scheduled
- B. Hold the scheduled dose and notify the physician
- C. Decrease the dosage from 100 mg to 50 mg
- D. Increase the dosage to 200 mg from 100 mg
Correct Answer: B
Rationale: A Dilantin level of 30 mcg/mL is above the therapeutic range (10-20 mcg/mL), indicating toxicity risk. The nurse should hold the dose and notify the physician for further orders.
A public health nurse is preparing an educational handout about rubella, commonly known as measles. All of the following statements should be included in the informational handout EXCEPT
- A. Rubella can be spread by coughing and sneezing.'
- B. The incubation period for rubella is 3-7 days.'
- C. Signs and symptoms include high fever, runny nose, and cough.'
- D. Rubella can be spread by skin-to-skin contact.'
Correct Answer: B
Rationale: Rubella’s incubation period is 12-23 days, not 3-7 days. It spreads via respiratory droplets (coughing/sneezing), not skin-to-skin. Symptoms include fever and rash, but runny nose and cough are more typical of measles.
A client in restraints is assigned to a newly graduated nurse. The nurse understands that which of the following are true regarding restraints? Select all that apply.
- A. Restraints can be chemical, mechanical, or physical.
- B. Children under 9 years of age have a 30-minute time limit in restraints.
- C. Bed rails are a form of restraint if used to prevent the client from leaving the bed.
- D. Restraints must be assessed every 2 hours for proper application and continued need.
- E. Once released, the client may be placed back in restraints for up to 24 hours if needed.
- F. Active listening, diversionary techniques, and reducing stimulation are alternatives to restraints.
Correct Answer: A, C, F
Rationale: Restraints include chemical, mechanical, or physical methods; bed rails are restraints if used to restrict movement; and non-restraint alternatives like active listening are preferred. Pediatric time limits and reassessment frequency vary by policy, and reapplication requires new orders.
Which of the following best describes the language of a 24-month-old?
- A. Doesn't understand yes and no
- B. Understands the meaning of words
- C. Able to verbalize needs
- D. Asks 'why?' to most statements
Correct Answer: C
Rationale: A 24-month-old can verbalize needs using simple words or phrases, reflecting their developing language skills.
Twenty micrograms (g) are equal to how many milligrams? Record your answer using a decimal number.
Correct Answer: 0.02
Rationale: 1 mg = 1,000 g, so 20 /1,000 = 0.02 mg.