Nokea
The nurse is caring for an adult who had a nephrectomy this morning. Because of the location of the surgery, the nurse knows that the client is at increased risk for which of the following?
- A. Thrombophlebitis
- B. Wound infection
- C. Atelectasis
- D. Footdrop
Correct Answer: C
Rationale: Nephrectomy involves flank incision near the diaphragm; postoperative pain limits deep breathing, increasing atelectasis risk. Thrombophlebitis, infection, or footdrop are less specific to the site.
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The nurse is auscultating the chest of a client with heart failure. The nurse should assess for which finding as an early sign of volume overload?
- A. S3 heart sound
- B. Murmur
- C. S4 heart sound
- D. Hypoventilation
Correct Answer: A
Rationale: S3 heart sound. This is an early sign of volume overload due to fluid in the ventricles during diastole.
The nurse is caring for a six-year-old boy several hours after the application of a hip spica cast.
- A. What should the nurse do first for a six-year-old complaining of pain in his left foot several hours after hip spica cast application?
- B. Elevate the left leg on two pillows.
- C. Palpate the cast for warmth and wetness.
- D. Administer pain medication as ordered.
- E. Check the blanching sign on both feet.
Correct Answer: D
Rationale: Pain in the foot post-cast application suggests possible circulatory impairment. Checking the blanching sign (capillary refill) assesses circulation, comparing the affected and unaffected sides. Elevation, palpation, or medication may follow but do not address the urgent need to assess circulation.
A baby boy is delivered after a rapid labor of three hours. What nursing action takes priority in the immediate newborn period?
- A. Suctioning with a bulb syringe
- B. Wrapping the baby in warm blankets
- C. Applying identification bracelets and taking footprints
- D. Assigning an APGAR score
Correct Answer: A
Rationale: Suctioning with a bulb syringe clears airways, ensuring respiratory patency, the priority in the immediate newborn period to prevent aspiration.
The nurse is caring for a client with a history of leukemia.
- A. Which laboratory finding is most concerning for a client with leukemia?
- B. White blood cell count of 50,000/mm³.
- C. Platelet count of 20,000/mm³.
- D. Hemoglobin of 11.0 g/dL.
- E. Serum potassium of 4.0 mEq/L.
Correct Answer: B
Rationale: A platelet count of 20,000/mm³ indicates severe thrombocytopenia, risking life-threatening bleeding in leukemia. Elevated WBC is expected, low hemoglobin is common, and normal potassium is unremarkable.
A client is placed on sulfamethoxazole-trimethoprim (Bactrim) for a recurrent urinary tract infection. Which of the following is appropriate reinforcement of information by the nurse?
- A. Drink at least 8 glasses of water a day.
- B. Be sure to take the medication with food.
- C. It is safe to take with oral contraceptives.
- D. Stop the medication after 5 days.
Correct Answer: A
Rationale: Bactrim is a highly insoluble drug and requires a large volume of fluid intake. It is not necessary to take it with food. Options C and D are incorrect instructions for those taking Bactrim.