Nokea
While managing a client after a medical or surgical procedure for bladder stones, for what rise in the temperature should the nurse notify the physician?
- A. When the temperature rises above 101F
- B. When the temperature rises above 100F
- C. When the temperature rises above 102F
- D. When the temperature rises above 99F
Correct Answer: C
Rationale: A rise in temperature is concerning after a medical or surgical procedure as it can indicate infection or other complications. A temperature above 102F is typically considered a significant fever, especially in the postoperative period. It is essential to notify the physician promptly to assess the patient's condition and provide appropriate interventions to address the underlying cause of the fever.
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Why should the nurse closely monitor a client to ensure that the venous access device remains in the vein during a transfusion?
- A. It minimizes the risk of phlebitis
- B. It minimizes the risk of circulatory overload
- C. It minimizes the risk of pulmonary
- D. It minimizes the risk of localized edema embolism
Correct Answer: D
Rationale: Keeping the venous access device securely in the vein during a transfusion is important to minimize the risk of localized edema embolism. If the device dislodges and infiltrates into surrounding tissues, it can lead to localized swelling, pain, and potential complications such as tissue damage. Monitoring ensures proper placement and function of the device, reducing the risk of complications related to dislodgment.
A female child, age 6, is brought to the health clinic for a routine checkup. To assess the child's vision, the nurse should ask:
- A. "Do you have any problems seeing different colors?"
- B. "Do you have trouble seeing at night?"
- C. "Do you have problems with glare?"
- D. "How are you doing in school?"
Correct Answer: A
Rationale: Asking the child if they have any problems seeing different colors is a suitable way to assess their vision during a routine checkup. Issues with colors can indicate potential color blindness or other vision problems. Asking about night vision (choice B) or glare (choice C) might be more relevant in specific situations or with older patients. Inquiring about their performance in school (choice D) could provide information related to vision but is not as direct and specific as asking about color vision.
A patient has a positive Homans' sign. Which of the ff. does the nurse understand explains why ambulation and performing the Homans' sign is now contraindicated?
- A. They can cause calf swelling c.They can cause an emboli
- B. They can cause patient pain
- C. They may cause a clot to form
Correct Answer: C
Rationale: A positive Homans' sign indicates possible deep vein thrombosis (DVT) in the leg. When a patient has DVT, the clot may dislodge and travel to the lungs, causing a pulmonary embolism, which can be life-threatening. Therefore, ambulation and performing the Homans' sign can dislodge the clot and potentially cause an embolism. It is contraindicated to prevent this serious complication.
A 16-year-old male with cystic fibrosis is hospitalized for 2 weeks for IV antibiotics. Which action will most enhance his psychosocial development?
- A. Fax his teacher and have homework sent in.
- B. Encourage his friends to visit him in the hospital.
- C. Encourage frequent visits from his grandparents.
- D. Allow him unlimited phone use to contact friends.
Correct Answer: B
Rationale: Peer interactions are crucial during adolescence; having friends visit helps him feel connected and 'normal.'
A healthy 4-year-old child has a left flank mass. Computerized tomography (CT) scan of the abdomen shows a localized renal mass. Radical nephrectomy is performed; the histology shows clear cell sarcoma of the kidney. The MOST appropriate next step in the management is
- A. CT scan of the chest
- B. CT scan of the brain
- C. bone scan
- D. magnetic resonance imaging (MRI) of the brain
Correct Answer: C
Rationale: Clear cell sarcoma of the kidney has a propensity to metastasize to bones, making a bone scan essential.