Nokea
The nurse is caring for an adult who had an appendectomy 6 hours ago. Which intervention would the nurse expect to perform to promote rest and sleep? Select all that apply.
- A. provide a substantial meal of meatloaf, mashed potatoes, corn, and milk
- B. offer Ambien 5 mg as ordered
- C. lower the temperature of the room
- D. change bed linen
Correct Answer: B, C, D
Rationale: Ambien, a cool room, and fresh linens promote rest. A heavy meal may disrupt sleep post-surgery.
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The teenager with a fiberglass cast asks the nurse if it will be okay to allow his friends to autograph his cast. Which response would be best?
- A. It will be alright for your friends to autograph the cast.
- B. Because the cast is made of plaster, autographing can weaken the cast.
- C. If they don't use chalk to autograph, it is okay.
- D. Autographing or writing on the cast in any form will harm the cast.
Correct Answer: A
Rationale: Autographing a fiberglass cast does not compromise its integrity, making it safe.
The nurse is caring for a client who was admitted to the burn unit 4 hours after the injury with second-degree burns to the trunk and head. Which finding would the nurse least expect to find during this time period?
- A. Hypovolemia
- B. Laryngeal edema
- C. Hypernatremia
- D. Hyperkalemia
Correct Answer: C
Rationale: Hypernatremia is least expected within 4 hours of a burn injury, as fluid shifts typically cause hyponatremia due to third-spacing. Hypovolemia, laryngeal edema, and hyperkalemia are common early findings.
The nurse is performing an initial assessment of a newborn Caucasian male delivered at 32 weeks gestation. The nurse can expect to find the presence of:
- A. Mongolian spots
- B. Scrotal rugae
- C. Head lag
- D. Polyhydramnios
Correct Answer: C
Rationale: Head lag is expected in a preterm newborn at 32 weeks due to underdeveloped neck muscle strength.
The nurse is assessing a client for hypovolemia. Which laboratory result would help the nurse in confirming a volume deficit?
- A. Hematocrit 55%
- B. Potassium 5.0 mEq/L
- C. Urine specific gravity 1.016
- D. BUN 18 mg/dL
Correct Answer: A
Rationale: Hypovolemia causes hemoconcentration, increasing hematocrit (e.g., 55% is elevated). Potassium, urine specific gravity, and BUN within normal ranges don't confirm volume deficit.
The nurse is caring for a client who is postoperative day 3 following a bowel resection. The client reports sudden, severe abdominal pain and distention. Which of the following actions should the nurse take FIRST?
- A. Administer pain medication as ordered.
- B. Notify the physician.
- C. Assess the client’s vital signs and abdomen.
- D. Encourage the client to ambulate.
Correct Answer: B
Rationale: sudden, severe abdominal pain and distention may indicate a complication such as an anastomotic leak, requiring immediate physician notification