Nokea
The nurse working on a medical-surgical unit receives change-of-shift report on several clients. Which client should the nurse see first?
- A. Client after a colonoscopic polypectomy today with abdominal cramping and a small amount of rectal bleeding
- B. Client after a laparoscopic inguinal hernia repair yesterday who reports urinary hesitancy while voiding
- C. Client after a lumbar laminectomy with spinal fusion 3 days ago who reports straining to have a bowel movement
- D. Client after a placement of an arteriovenous graft 3 days ago with a temperature of 100.9 F (38.3 C)
Correct Answer: D
Rationale: A fever of 100.9 F post-arteriovenous graft suggests possible infection, requiring immediate assessment. Cramping and minor bleeding are expected post-polypectomy, urinary hesitancy is common post-hernia repair, and straining is less urgent.
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A client is experiencing an exacerbation of chronic lower back pain after working in the yard all weekend. The nurse should reinforce the primary importance of which nonpharmacologic intervention for acute muscle pain?
- A. Heating pad
- B. Positioning for comfort
- C. Rest from pain-aggravating activities
- D. Stretching exercises
Correct Answer: C
Rationale: For acute lower back pain, rest from aggravating activities is primary to prevent further strain. Heat and positioning are helpful but secondary, and stretching may worsen acute pain.
The graduate nurse (GN) is reinforcing education on sitting on and standing up from a chair to a client with crutches. Which instruction by the GN would cause the supervising nurse to intervene?
- A. Hold a crutch in each hand for support when standing up from a chair
- B. Move to the edge of the chair before standing and use the unaffected leg to rise
- C. Touch the back of the unaffected leg to the chair before preparing to sit
- D. Use an armrest or seat for assistance when lowering the body into a chair
Correct Answer: A
Rationale: Holding a crutch in each hand is incorrect as crutches should be placed together on the unaffected side or against a stable surface to free the hands for support when standing. Other instructions (B, C, D) are correct for safe crutch use during sitting and standing.
A 67 year-old client with non-insulin dependent diabetes should be instructed to contact the out-patient clinic immediately if the following findings are present
- A. Temperature of 99.5 degrees Fahrenheit with painful urination
- B. An open, reddened wound on the heel
- C. Insomnia and daytime fatigue
- D. Nausea with 2 episodes of vomiting
Correct Answer: B
Rationale: An open, reddened wound on the heel. When signs of trauma and/or infection occur in their feet, elderly clients who have diabetes and/or vascular disease should seek health care quickly and continue treatment until the problem is resolved. Without treatment, serious infection, gangrene, limb loss, and death may result.
The nurse is auscultating the lungs in a postoperative client and hears something that sounds like a cellophane bag being wrinkled when the client takes in a breath. How should the nurse record this finding?
- A. Crackles
- B. Stridor
- C. Stertor
- D. Wheezes
Correct Answer: A
Rationale: Crackles, sounding like crinkling cellophane, indicate fluid in alveoli or airway collapse, common post-surgery. Stridor, stertor, and wheezes have different characteristics.
While assessing the vital signs in children, the nurse should know that the apical heart rate is preferred until the radial pulse can be accurately assessed at about what age?
- A. 1 year of age
- B. 2 years of age
- C. 3 years of age
- D. 4 years of age
Correct Answer: B
Rationale: 2 years of age. A child should be at least 2 years of age to use the radial pulse to assess heart rate.