Nokea
The nurse plans care for a 25-year-old woman immediately after a cesarean section. Which of the following nursing goals is MOST important?
- A. Prevent infection.
- B. Prevent fluid and electrolyte imbalances.
- C. Provide for pain management.
- D. Prevent hazards of immobility.
Correct Answer: B
Rationale: hemorrhage and shock most life-threatening conditions that occur after surgery
You may also like to solve these questions
The nurse is caring for a client with a new tracheostomy.
- A. What is the priority nursing intervention for a client with a new tracheostomy?
- B. Suction the tracheostomy every 2 hours.
- C. Change the tracheostomy ties daily.
- D. Monitor the stoma for signs of infection.
- E. Keep the tracheostomy cuff inflated at all times.
Correct Answer: C
Rationale: Monitoring the stoma for signs of infection is the priority to detect complications early, ensuring airway safety. Suctioning is as needed, ties are changed as needed, and continuous cuff inflation risks tracheal damage.
A 22-year-old mother of a 4-year-old boy comes to the antepartal clinic. Her second pregnancy has just been confirmed.
During this initial visit, it MOST important for the nurse to
- A. assess the client's feelings about pregnancy, labor, and delivery.
- B. obtain a history of the client's last labor and delivery.
- C. determine how the client's 4-year-old feels about the pregnancy.
- D. identify the client's general health needs.
Correct Answer: D
Rationale: Strategy: Think about each answer choice. (1) important data, priority is the here and now (2) important data, but not priority for first visit (3) important data, need to deal with the mother's needs first (4) correct-optimal opportunity for preventative health maintenance
A 36-year-old client tested positive for the tuberculosis antibody and was placed on isoniazid (INH) four weeks ago. The nurse would be MOST concerned if which of the following was observed?
- A. Fatigue and dark urine.
- B. Malaise and glucosuria.
- C. Proteinuria and lethargy.
- D. Diluted urine and epigastric distress.
Correct Answer: A
Rationale: initial indications of hepatic dysfunction
The nurse is caring for a client with a history of depression who is receiving fluoxetine (Prozac) 20 mg PO daily. Which of the following client statements would be of GREATest concern to the nurse?
- A. I feel tired in the afternoon.
- B. I have a dry mouth.
- C. I think about ending my life.
- D. I take my medication with food.
Correct Answer: C
Rationale: Thoughts of ending life indicate suicidal ideation, a medical emergency requiring immediate intervention in a client on fluoxetine. Options A, B, and D are less concerning: fatigue and dry mouth are common side effects, and taking with food is acceptable.
The nurse is caring for a client who is receiving a continuous IV infusion of fentanyl for pain management. Which of the following findings should the nurse report immediately?
- A. Respiratory rate of 10 breaths/min
- B. Blood pressure of 120/80 mmHg
- C. Heart rate of 80 bpm
- D. Oxygen saturation of 95%
Correct Answer: A
Rationale: A respiratory rate of 10 breaths/min indicates respiratory depression, a serious fentanyl side effect. Options B, C, and D are normal findings.