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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The nurse is caring for a client who is postoperative day 1 after a coronary artery bypass graft (CABG). Which of the following findings should the nurse report immediately?
- A. Heart rate of 90 bpm.
- B. Temperature of 100.8°F (38.2°C).
- C. Chest tube drainage of 50 mL/hour.
- D. Blood pressure of 130/80 mmHg.
Correct Answer: B
Rationale: A temperature of 100.8°F suggests infection, a serious post-CABG complication. Options A, C, and D are normal or expected.
The nurse is caring for a client with pancreatitis experiencing the process of lipolysis of the pancreas. Which assessment would be a priority because of the pathophysiology of lipolysis?
- A. Checking for tetany-like movements
- B. Assessing breath sounds
- C. Obtaining vital signs
- D. Palpating pedal pulses
Correct Answer: A
Rationale: Hypocalcemia is a specific manifestation of clients with pancreatitis and lipolysis, and tetany is a major characteristic of low calcium levels. Answers B, C, and D are all pertinent assessments but are not priorities with the pathophysiology of lipolysis, so they are incorrect.
The nurse is assessing a client immediately after an exploratory laparotomy. Which of the following nursing observations would relate to the complication of inTest inal obstruction?
- A. Protruding soft abdomen with frequent diarrhea.
- B. Distended abdomen with ascites.
- C. Minimal bowel sounds in all four quadrants.
- D. Distended abdomen with complaints of pain.
Correct Answer: D
Rationale: if an obstruction is present, the abdomen will become distended and painful
The nurse is caring for a client with a history of chronic pain.
- A. Which intervention is most effective for managing chronic pain?
- B. Administer analgesics as needed only.
- C. Encourage participation in a pain management program.
- D. Restrict physical activity to reduce pain.
- E. Apply ice packs to the painful area.
Correct Answer: B
Rationale: A pain management program (e.g., cognitive-behavioral therapy, physical therapy) addresses chronic pain holistically, improving function and coping. PRN analgesics are less effective long-term, activity is encouraged, and ice is condition-specific.
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.