Nokea
The nurse is caring for a post-operative client who develops a wound evisceration. The first nursing intervention should be
- A. medicate the client for pain
- B. call the provider
- C. cover the wound with sterile saline dressing
- D. place the bed in a flat position
Correct Answer: C
Rationale: When evisceration occurs, the wound should first be quickly covered by sterile dressings soaked in sterile saline. This prevents tissue damage until a repair can be effected.
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It is MOST important for the nurse to assess for which of the following?
- A. Tachycardia.
- B. Diarrhea.
- C. Peripheral edema.
- D. Impotence.
Correct Answer: C
Rationale: Strategy: Determine how each answer choice relates to medication. (1) will cause bradycardia (2) usually causes constipation (3) correct-Calan is a calcium-channel blocker, depresses myocardial contractility, decreases work of ventricles and O2 demand, dilates coronary arteries, when used with other antihypertensives can cause hypotension and heart failure (4) not most important or frequent side effect
The nurse is caring for a client with a history of hypertension who is receiving hydralazine (Apresoline) 25 mg PO tid. Which of the following findings should the nurse report immediately?
- A. Blood pressure of 130/80 mmHg
- B. Heart rate of 100 bpm
- C. Chest pain and shortness of breath
- D. Mild headache
Correct Answer: C
Rationale: Chest pain and shortness of breath suggest angina or lupus-like syndrome, serious hydralazine side effects. Options A, B, and D are less urgent: BP is normal, tachycardia is mild, and headache is common.
The client has just had a basal cell carcinoma removed in the doctor's office. Which statement the client makes indicates understanding regarding prevention and early detection of basal cell carcinoma?
- A. Moles that are round and brown should be seen immediately by my doctor.'
- B. I should wear long sleeves when I am out in the sun.'
- C. I should avoid using lotions and powders on my skin.'
- D. I can use a tanning booth to get a tan since I can't stay in the sun very long.'
Correct Answer: B
Rationale: Long sleeves protect against UV exposure, a key risk for basal cell carcinoma. Moles, lotions, or tanning booths are unrelated or harmful.
The nurse is caring for a client who is receiving a blood transfusion. Which of the following findings would be of GREATest concern to the nurse?
- A. Temperature of 100.4°F (38°C).
- B. Heart rate of 90 bpm.
- C. Respiratory rate of 18 breaths/min.
- D. Blood pressure of 120/80 mmHg.
Correct Answer: A
Rationale: A temperature of 100.4°F during a blood transfusion suggests a transfusion reaction, such as febrile non-hemolytic reaction, requiring immediate cessation of the transfusion. Options B, C, and D are normal: heart rate 90 bpm, respiratory rate 18 breaths/min, and blood pressure 120/80 mmHg do not indicate complications.
The client says to the nurse, 'I don't see why I should live any longer.' How should the nurse respond initially?
- A. Ask the client why she doesn't want to live any longer
- B. Ask the client if she is considering suicide
- C. Tell the client that life is precious and worth living
- D. Help the client see the good things that she has in her life
Correct Answer: B
Rationale: Expressing a desire to not live suggests suicidal ideation; directly asking about suicide assesses risk and guides intervention. Exploring reasons, affirming life, or highlighting positives are secondary.