Nokea
The unlicensed assistive personnel (UAP) reports the vital signs for a first-day postoperative client as T 100.8°F, P 80, R 24, and BP 148/80. Which intervention would be most appropriate for the nurse to implement?
- A. Administer the antibiotic earlier than scheduled.
- B. Change the dressing over the wound.
- C. Have the client turn, cough, and deep breathe every two (2) hours.
- D. Encourage the client to ambulate in the hall.
Correct Answer: C
Rationale: A low-grade fever (100.8°F) and tachypnea (R 24) suggest atelectasis; turning, coughing, and deep breathing prevent respiratory complications. Antibiotics, dressing changes, and ambulation are secondary.
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Which technique would be most appropriate for the nurse to implement when assessing a four (4)-year-old client in acute pain?
- A. Use words a four (4)-year-old child can remember.
- B. Explain the 0-to-10 pain scale to the child's parent.
- C. Have the child point to the face which describes the pain.
- D. Administer the medication every four (4) hours.
Correct Answer: C
Rationale: The FACES pain scale (pointing to faces) is age-appropriate for a 4-year-old, per pediatric pain assessment guidelines. Simple words are vague, numeric scales are for older children, and scheduled medication is not assessment.
The client received naloxone (Narcan), an opioid antagonist, in the postanesthesia care unit. Which nursing intervention should the nurse include in the care plan?
- A. Measure the client's intake and output hourly.
- B. Administer sleep medications at night.
- C. Encourage the client to verbalize feelings.
- D. Monitor respirations every 15 to 30 minutes.
Correct Answer: D
Rationale: Narcan reverses opioid-induced respiratory depression, requiring frequent respiratory monitoring to detect recurrence. I&O, sleep aids, and verbalization are secondary.
Which laboratory result would require immediate intervention by the nurse for the client scheduled for surgery?
- A. Calcium 9.2 mg/dL.
- B. Bleeding time two (2) minutes.
- C. Hemoglobin 15 g/dL.
- D. Potassium 2.4 mEq/L.
Correct Answer: D
Rationale: Hypokalemia (2.4 mEq/L, normal 3.5–5.0) risks arrhythmias during anesthesia, requiring immediate intervention. Normal calcium, bleeding time, and hemoglobin are safe.
Which problem would be most appropriate for the nurse to identify for the client experiencing acute pain?
- A. Ineffective coping.
- B. Potential for injury.
- C. Alteration in comfort.
- D. Altered sensory input.
Correct Answer: C
Rationale: Alteration in comfort directly addresses acute pain’s impact, per NANDA-I. Coping, injury, and sensory input are secondary or unrelated.
Which client would the nurse identify as having the highest risk for developing postoperative complications?
- A. The 67-year-old client who is obese, has diabetes, and takes insulin.
- B. The 50-year-old client with arthritis taking nonsteroidal anti-inflammatory drugs.
- C. The 45-year-old client having abdominal surgery to remove the gallbladder.
- D. The 60-year-old client with anemia who smokes one (1) pack of cigarettes a day.
Correct Answer: A
Rationale: Obesity, diabetes, and insulin use increase risks for infection, poor wound healing, and glycemic instability, the highest risk profile. Arthritis, cholecystectomy, and anemia/smoking are less severe.