Nokea
Thirty-six hours after major surgery, a client has a temperature of 100°F. What is the most likely cause of the temperature elevation?
- A. Dehydration
- B. Atelectasis
- C. Wound infection
- D. Bladder infection
Correct Answer: B
Rationale: Atelectasis, due to reduced lung expansion post-surgery, is a common cause of low-grade fever within 24–48 hours. Dehydration, wound infection (typically later), or bladder infection are less likely without specific symptoms.
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The mother of a 2 year-old hospitalized child asks the nurse's advice about the child's screaming every time the mother gets ready to leave the hospital room. What is the best response by the nurse?
- A. I think you or your partner needs to stay with the child while in the hospital.'
- B. Oh, that is expected, so I would just ignore the behavior.'
- C. Perhaps you could gradually leave for short periods.'
- D. You should leave quickly to minimize the child's distress.'
Correct Answer: C
Rationale: Gradually increasing the time of separation can help the child adjust to the mother's absence, reducing anxiety and screaming over time.
A client with a fractured hip asks the nurse about activity after discharge. The nurse should explain to the client that she should refrain from which of the following activities?
- A. Crossing her legs at the knee
- B. Sitting in a recliner
- C. Walking up stairs
- D. Carrying objects that weigh more than 10 pounds
Correct Answer: A
Rationale: Crossing legs at the knee can cause hip adduction, risking dislocation in a fractured hip. Other activities are generally safe with proper precautions.
The nurse is changing a dressing. Which event indicates a break in sterile technique?
- A. The nurse opens the sterile dressing set by opening the first flap away from herself.
- B. The nurse turns around when answering a question asked by the client in the other bed.
- C. The nurse opens the dressing set on the overbed table.
- D. The nurse pours sterile saline into the container in the dressing set.
Correct Answer: B
Rationale: Turning around risks contaminating the sterile field by passing non-sterile areas over it. Opening flaps away, using the table, or pouring saline maintain sterility.
A client with chronic heart failure calls the clinic to report a weight gain of 3 lb (1.4 kg) over the last 2 days. Which information is most important for the nurse to ask this client?
- A. Diet recall for this current week
- B. Fluid intake for the past 2 days
- C. Medications and dosages taken over the past 2 days
- D. Presence of shortness of breath, coughing, or edema
Correct Answer: D
Rationale: Symptoms like shortness of breath, coughing, or edema (D) indicate fluid overload, a critical concern in heart failure. Diet (A), fluid intake (B), and medications (C) are relevant but secondary.
The nurse is caring for an older adult client who is confused and has a high risk for falls. The client is incontinent of urine and frequently attempts to get out of bed unassisted to use the restroom. Which nursing interventions are appropriate when caring for this client? Select all that apply.
- A. Ensuring bed alarm remains activated
- B. Initiating an hourly rounding schedule
- C. Inserting an indwelling urinary catheter
- D. Moving client to a room close to the nurses' station
- E. Raising all side rails of the client's bed
Correct Answer: A,B,D
Rationale: Bed alarms (A), hourly rounding (B), and proximity to the nurses' station (D) enhance safety and monitoring. Catheters (C) increase infection risk and are not first-line, and raising all side rails (E) is a restraint and unsafe.