Nokea
The nurse is caring for a client who is postoperative day 2 following a total knee replacement. The client reports pain at the surgical site and has a temperature of 100.8°F (38.2°C). Which of the following actions should the nurse take FIRST?
- A. Administer an analgesic as ordered.
- B. Notify the physician.
- C. Apply a cold pack to the surgical site.
- D. Assess the surgical site for signs of infection.
Correct Answer: D
Rationale: assessing the surgical site for signs of infection is the first step to determine the cause of the fever and pain
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A client with tuberculosis has a prescription for Myambutol (ethambutol HCl). The nurse should tell the client to notify the doctor immediately if he notices:
- A. Gastric distress
- B. Changes in hearing
- C. Red discoloration of body fluids
- D. Changes in color vision
Correct Answer: D
Rationale: Ethambutol can cause optic neuritis, leading to changes in color vision, a serious side effect requiring immediate medical attention.
Which client is at the greatest risk of developing colon cancer?
- A. a 83-year-old Hispanic female with a past history of cholecystectomy
- B. a 62-year-old African American male with a past history of diabetes
- C. a 70-year-old Caucasian male with a past history of cancer treated with chemotherapy
- D. a 42-year-old Asian female who follows a high-fiber diet
Correct Answer: C
Rationale: Previous cancer history, especially treated with chemotherapy, increases colon cancer risk due to potential genetic or environmental factors. Age over 50 also elevates risk.
The nurse has an order to give 1,000 mL of 0.9% NS with 20 meQ of potassium chloride over 8 hours. The IV set has a drop factor of 15. How many gtts/min should the client receive?
Correct Answer: 31
Rationale: Rate = 1,000 mL ÷ 8 hr = 125 mL/hr. Drops/min = (125 mL/hr × 15 gtts/mL) ÷ 60 min = 31.25 gtts/min, rounded to 31 gtts/min.
The nurse has performed nutritional teaching on a client with gout who is placed on a low-purine diet. Which selection by the client would indicate that teaching has been ineffective?
- A. Cabbage
- B. Apple
- C. Peach cobbler
- D. Spinach
Correct Answer: D
Rationale: Spinach is high in purines, which can exacerbate gout. Cabbage, apples, and peach cobbler (if low in purine ingredients) are suitable for a low-purine diet.
Which assessment finding would the nurse expect in a client with long-term venous insufficiency with the presence of a venous ulcer?
- A. decreased or absent pedal pulses with cool or cold foot
- B. the presence of stasis ulcers over the medial malleolus
- C. skin atrophy and pallor with elevation of the affected leg
- D. decreased circumference in the affected leg due to venous constriction
Correct Answer: B
Rationale: Venous insufficiency causes stasis ulcers, typically over the medial malleolus, due to venous pooling and tissue breakdown.