Nokea
The nurse is caring for a postcholecystectomy client who had the T-tube removed this AM. Two hours after removal of the T-tube, the nurse notes that the 4x4 dressing covering the stab site is saturated with dark, greenish-yellow drainage. It is MOST appropriate for the nurse to take which of the following actions?
- A. Remove the dressing and replace it with a more absorbent dressing.
- B. Collect a culture and sensitivity specimen of the drainage.
- C. Observe the wound for dehiscence.
- D. Reinforce the dressing with an 8x10 dressing.
Correct Answer: A
Rationale: expected that a stab wound will continue to drain until the wound seals; nurse should keep wound clean and dry
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Which of the following groups of neonates should be screened for hearing loss?
- A. Premature neonates.
- B. Neonates with risk factors for hearing loss.
- C. Neonates with abnormal Apgar scores.
- D. All neonates.
Correct Answer: D
Rationale: Universal newborn hearing screening is recommended for all neonates (D) to detect hearing loss early. Premature neonates (A), those with risk factors (B), or abnormal Apgar scores (C) are included but not exclusive.
The nurse is creating a discharge plan for a client with cholecystitis. The nurse should encourage the client to follow
- A. a diet low in potassium.
- B. a diet low in fat.
- C. a diet with increased vitamin B12.
- D. a diet low in phosphorus.
Correct Answer: B
Rationale: A low-fat diet reduces gallbladder stimulation and prevents cholecystitis flare-ups. Potassium, B12, and phosphorus are not directly related to cholecystitis management.
When assessing a client's skin, the nurse notes a scattered red rash on the trunk. The individual lesions are about 0.5 cm in diameter and are flat, nonpalpable, and circumscribed. How would this type of lesion be classified?
- A. Papule
- B. Nodule
- C. Macule
- D. Patch
Correct Answer: C
Rationale: A flat, nonpalpable lesion ≤1 cm is a macule (C). Papules (A) are raised, nodules (B) are deeper and larger, and patches (D) are larger flat lesions.
The nurse is preparing the client for surgery. The pre-op medication includes atropine sulfate 0.4 mg, meperidine (Demerol HCl) 50 mg, and promethazine hydrochloride (Phenergan) 25 mg IM. Which action should the nurse do first?
- A. make sure the surgical permit is signed
- B. ask the client to go to the bathroom
- C. explain the purpose of the medication to the client
- D. ask family members to exit the room
Correct Answer: A
Rationale: Ensuring the surgical permit is signed is the priority to confirm informed consent before administering preoperative medications.
The nurse is caring for a client with possible cervical cancer. What clinical data would the nurse most likely find in the client's history?
- A. Post-coital vaginal bleeding
- B. Nausea and vomiting
- C. Foul-smelling vaginal discharge
- D. Hyperthermia
Correct Answer: A
Rationale: Post-coital vaginal bleeding is a hallmark symptom of cervical cancer due to tumor friability. The other symptoms are less specific or related to advanced disease.