Nokea
The nurse is caring for a client with a recently fractured left tibia who is grimacing and slightly diaphoretic. The nurse should initially
- A. Perform range of motion with the client's left leg.
- B. Obtain the client's temperature.
- C. Assess the client for pain.
- D. Administer prescribed oxycodone-acetaminophen.
Correct Answer: C
Rationale: Grimacing and diaphoresis suggest pain, which should be assessed first to guide interventions. Range of motion may worsen pain, temperature is secondary, and medication administration requires prior assessment.
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Nurses’ Notes
1930 – Assessment completed
Peripheral pulses were all palpable. S1/S2 heart tones auscultated. No peripheral edema.
Lung sounds were clear in all fields. Client denied any cough or dyspnea. Respirations were regular and unlabored.
Bowel sounds were active in all quadrants, with no abdominal distention noted. Client only reports nausea after her prescribed acetaminophen-oxycodone.
Surgical incisions appeared approximated, reddened, and the surrounding area was hot to touch. Small amount of foul-smelling, purulent type of drainage was noted. The gauze dressing was changed, and a new gauze dressing was applied.
Client reported intermittent incisional pain of 3/10 described as ‘sore’. Vital Signs: Oral Temperature 100.4° F (38° C)
Pulse 93/minute
Respirations 18/minute
Blood pressure 111/69 mm Hg
O2 saturation 95% on room air
The nurse performs a physical assessment for a client three days post-operative following a radical hysterectomy.Select three (3) assessment and vital sign findings that are highly concerning.
- A. Incisional pain
- B. Approximated wounds
- C. Pulse rate
- D. Foul smelling drainage
- E. Nausea after pain medication
- F. Oral temperature
- G. Purulent wound drainage
Correct Answer: D,F,G
Rationale: This client is demonstrating signs and symptoms of a surgical site infection. The findings requiring follow-up include the foul-smelling drainage that is purulent. Further, this client also has a concern for their oral temperature as it is a clinical fever.
Findings that are not highly concerning include the client’s incisional pain which is described as sore and is intermittent. This is an expected finding following surgery. The wounds being approximated is an optimal finding. The client’s pulse is within normal limits. Finally, nausea after pain medication is a common side-effect.
Which of the following children would the nurse identify as a priority for having the greatest risk for choking and suffocating?
- A. A toddler playing with his 9-year-old brother's construction set.
- B. A 5-year-old eating yogurt for a snack.
- C. An infant asleep in her crib without a blanket.
- D. A 3-year-old drinking a glass of juice.
Correct Answer: A
Rationale: A toddler playing with small construction set pieces is at high risk for choking due to the size and accessibility of the objects.
The nurse is caring for a client eight hours following a total thyroidectomy. The nurse plans on obtaining an order to assess the client's serum
- A. potassium level
- B. calcium level
- C. sodium level
- D. glucose level
Correct Answer: B
Rationale: Total thyroidectomy can disrupt parathyroid function, leading to hypocalcemia due to decreased parathyroid hormone. Monitoring serum calcium levels is critical to detect and manage this complication. Potassium, sodium, and glucose levels are less directly affected by thyroidectomy.
The nurse is educating a client who has stomatitis on oral care. Which of the following recommendations would be appropriate?
- A. Recommend the client swish and spit alcohol mouthwash.
- B. Provide lemon glycerin swabs in between meals.
- C. Recommend the client swish and spit saline mouthwash.
- D. Instruct the client to cleanse their mouth with chlorhexidine.
Correct Answer: C
Rationale: Saline mouthwash soothes stomatitis without irritation. Alcohol mouthwash and lemon swabs are harsh, and chlorhexidine may be prescribed but isn’t the primary recommendation.
The nurse is performing health screenings on a group of refugees. The nurse plans on performing which screening for this population group? Select all that apply.
- A. Hypothyroidism
- B. Attention deficit hyperactivity disorder (ADHD)
- C. Pulmonary tuberculosis
- D. Intestinal parasites
- E. Viral hepatitis
Correct Answer: C,D,E
Rationale: Refugees are at higher risk for tuberculosis, intestinal parasites, and viral hepatitis due to living conditions and exposure risks.