Nokea
The nurse is conducting walking rounds and observes the client (see figure). The nurse should do which of the following?
- A. Loosen the bed restraints so the client can sit up.
- B. Raise the side rails to full upright position.
- C. Assess the client to determine why she wants to sit up.
- D. Elevate the head of the bed.
Correct Answer: C
Rationale: The nurse should fi rst determine why the client wants to sit up, and then, if needed delegate someone to assist the client. Loosening the restraints will not keep the client safe in bed. Raising theside rails and elevating the head of the bed do not address the client’s needs.
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Which sign/symptom is an indication that the client experiencing postoperative blood loss is anemic?
- A. Fatigue
- B. Dyspnea
- C. Bradycardia
- D. Muscle cramps
Correct Answer: A
Rationale: The client with anemia is likely to report fatigue caused by deficient hemoglobin leading to a decreased oxygen-carrying capacity of the blood and ability to meet tissue oxygen demands. The respiratory rate can increase to improve oxygenation; some shortness of breath can occur but dyspnea related to anemia is uncommon. The client is more likely to have tachycardia than bradycardia, because the heart beats faster to deliver the same amount of oxygen to tissues in compensation for less oxygen in the blood. Muscle cramps are an unrelated finding.
A child has been prescribed diphenhydramine hydrochloride (Benadryl) to help control the itching from atopic dermatitis. The nurse should instruct the parents to report: Select all that apply.
- A. Weight loss.
- B. Drowsiness.
- C. Thickened bronchial secretions.
- D. Upset stomach.
- E. Bradycardia.
Correct Answer: B, C, D
Rationale: Diphenhydramine can cause drowsiness, thickened bronchial secretions, and upset stomach as side effects, which should be reported.
When cleaning the skin around an incision and drain site, which of the following procedures should the nurse follow?
- A. Clean the incision and drain site separately.
- B. Clean from the incision to the drain site.
- C. Clean from the drain site to the incision.
- D. Clean the incision and drain site simultaneously.
Correct Answer: A
Rationale: Cleaning separately prevents cross-contamination between the incision and drain site, reducing infection risk.
The nurse receives a client from the postanesthesia care unit who has had skeletal traction applied in the operating room. The nurse should take immediate action to correct which problem with the traction setup when it is noted?
- A. Knots are secured tightly.
- B. There are weights at both ends of the bed.
- C. Weights are resting against the foot of the bed.
- D. Pin site is exposed to air without any dressing.
Correct Answer: C
Rationale: The traction setup is checked to ensure that weights are hanging freely from the ropes and knots are tied securely. The weights should not be resting on the bed. Countertraction is commonly supplied by the client's body weight or by weights pulling in the opposite direction. Therefore, there can be weights at both ends of the bed. Pin-site care varies but usually includes regularly removing exudate with half-strength hydrogen peroxide, rinsing pin sites with sterile saline, and drying the area with sterile gauze; the pin site is left open to air. If any problems are noted, they should be fixed immediately.
The nurse is caring for a client with a history of burns covering 30% of the body. Which of the following interventions should be prioritized?
- A. Administer I.V. fluids.
- B. Apply antibiotic cream.
- C. Monitor for infection.
- D. Administer analgesics.
Correct Answer: A
Rationale: I.V. fluids are the priority to replace fluid loss and prevent hypovolemic shock in burn injuries.