A nurse is evaluating a postoperative patient and notes a moderate amount of serous drainage on the dressing 24 hours after surgery. Which of the following is the appropriate nursing action? A. Notify the surgeon about evidence of infection immediately. B. Leave the dressing intact to avoid disturbing the wound site. C.… Read More »
A patient returns to the emergency department less than 24 hours after having a fiberglass cast applied for a fractured right radius. Which of the following patient complaints would cause the nurse to be concerned about impaired perfusion to the limb? A. Severe itching under the cast. B. Severe pain in the right… Read More »
Nurse Bea should instruct the male client with an ileostomy to report immediately which of the following symptoms? A. Absence of drainage from the ileostomy for 6 or more hours B. Passage of liquid stool in the stoma C. Occasional presence of undigested food D. A temperature of 37.6 °C … Read More »
Nurse Lynette is preparing a site for the insertion of an I.V. catheter. The nurse should treat excess hair at the site by: A. Leaving the hair intact B. Shaving the area C. Clipping the hair in the area D. Removing the hair with a depilatory Correct… Read More »
Nurse Nikki knows that laboratory results supports the diagnosis of systemic lupus erythematosus (SLE) is: A. Elevated serum complement level B. Thrombocytosis, elevated sedimentation rate C. Pancytopenia, elevated antinuclear antibody (ANA) titer D. Leukocytosis, elevated blood urea nitrogen (BUN) and creatinine levels Correct Answer: C. Pancytopenia, elevated… Read More »
After a liver biopsy, place the patient in which of the following positions? A. Left side-lying, with the bed flat B. Right side-lying, with the bed flat C. Left side-lying, with the bed in semi-Fowler’s position D. Right side-lying, with the bed in semi-Fowler’s position Correct Answer:… Read More »
The nurse is caring for a client who had a total hip replacement seven (7) days ago. Which statement by the client requires the nurse’s immediate attention? A. I have bad muscle spasms in my lower leg of the affected extremity. B. “I just can’t ‘catch my breath’ over the past few minutes and I… Read More »
Which of the following potentially serious complications could occur with therapy for hypothyroidism? A. Acute hemolytic reaction B. Angina or cardiac arrhythmia C. Retinopathy D. Thrombocytopenia Correct Answer B. Angina or cardiac arrhythmia Precipitation of angina or cardiac arrhythmia is a potentially serious complication of hypothyroidism treatment.… Read More »
When evaluating an arterial blood gas from a male client with a subdural hematoma, the nurse notes the Paco2 is 30 mm Hg. Which of the following responses best describes the result? A. Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP). B. Emergent; the client is poorly oxygenated. C. Normal. D. Significant;… Read More »
A client is admitted to the labor and delivery unit in active labor. During the examination, the nurse notes a papular lesion on the perineum. Which initial action is most appropriate? A. Document the finding B. Report the finding to the doctor C. Prepare the client for a C-section D. Continue primary care… Read More »