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The nurse is conducting a postoperative assessment of a client on the first day after renal surgery. Which of the following findings would be most important for the nurse to report to the physician?
- A. Temperature, 99.8°F (37.7°C).
- B. Urine output, 20 mL/hour.
- C. Absence of bowel sounds.
- D. A 2€ x 2€ area of serosanguineous drainage on the flank dressing.
Correct Answer: B
Rationale: Urine output of 20 mL/hour is critically low, indicating potential renal compromise or obstruction, requiring immediate physician notification.
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On the fourth day after surgery, a client has a postoperative wound infection. Which of the following should the nurse assess? Select all that apply.
- A. Total white blood count (WBC) 10,000/mm³.
- B. Redness and swelling beyond the incision line.
- C. Temperature of 102°F (38.9°C).
- D. Client reports of pain at the incision site.
- E. Warmth at the incision site.
Correct Answer: B,C,D,E
Rationale: Signs of wound infection include redness/swelling (B), fever (C), pain (D), and warmth (E). A WBC of 10,000/mm³ (A) is normal and not indicative of infection.
The client asks the nurse to explain what it means that his Hodgkin's disease is diagnosed at stage 1A. Which of the following describes the involvement of the disease?
- A. Involvement of a single lymph node.
- B. Involvement of two or more lymph nodes on the same side of the diaphragm.
- C. Involvement of lymph node regions on both sides of the diaphragm.
- D. Diffuse disease of one or more extralymphatic organs.
Correct Answer: A
Rationale: Stage 1A Hodgkin's disease indicates involvement of a single lymph node region without B symptoms (fever, night sweats, weight loss). Higher stages involve multiple nodes or extralymphatic sites.
Which assessment is critical for a client with a recent stroke?
- A. Swallowing ability.
- B. Blood glucose.
- C. Cholesterol levels.
- D. Joint mobility.
Correct Answer: A
Rationale: Assessing swallowing ability is critical to prevent aspiration in stroke patients.
The nurse is reviewing discharge prescriptions for a child postoperative following a tonsillectomy. Which medication requires clarification with the primary healthcare provider?
- A. tetracaine 0.5% lollipop
- B. acetaminophen (APAP)
- C. ibuprofen
- D. codeine
Correct Answer: D
Rationale: Codeine is not recommended for children post-tonsillectomy due to risks of respiratory depression, especially in those with undiagnosed sleep apnea or ultra-rapid metabolism.
Which of the following guidelines reflects the current American Cancer Society recommendations for screening for colon cancer in individuals who are not at high risk?
- A. Annual digital rectal examination should begin at age 40.
- B. Annual fecal testing for occult blood should begin at age 50.
- C. Individuals should obtain a baseline barium enema at age 40.
- D. Individuals should obtain a baseline colonoscopy at age 45.
Correct Answer: B
Rationale: Annual fecal testing for occult blood should begin at age 50. Annual digital rectal examinations are recommended in men beginning at age 50 to screen for prostate cancer. Baseline barium enemas or colonoscopies are recommended at age 50. Baseline barium enemas and colonoscopies are not performed on individuals in their 40s unless they recommend the nurse to the need for such diagnostic testing, or are considered to be at high risk. CN: Health promotion and maintenance; CL: Apply