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While caring for a client's postoperative dressing, the nurse observes purulent drainage at the
wound. Before reporting this finding to the healthcare provider, the nurse should review which
of the client's laboratory values?
A. Serum albumin
B. Culture for sensitive organisms
C. Serum blood glucose level
D. Creatinine level B. Culture for sensitive organisms
A preschool-aged boy is admitted to the pediatric unit following successful resuscitation from a
near-drowning incident. While providing care to the child, the nurse begins talking with his
preadolescent brother who rescued the child from the swimming pool and initiated
resuscitation. The nurse notices the older boy becomes withdrawn when asked about what
happened. Which action should the nurse take?
A. Develop a water safety teaching plan for the family
,B. Ask the older brother how he felt during the incident
C. Tell the older brother that he seems depressed
D. Commend the older brother for his heroic actions B. Ask the older brother how he felt
during the incident
A male client with cirrhosis has jaundice and pruritus. He tells the nurse that he has been
soaking in hot baths at night with no relief of his discomfort. Which action should the nurse
take?
A. Encourage the client to use cooler water and apply calamine lotion after soaking
B. Obtain a PRN prescription for an analgesic that the client can use for symptom relief
C. Suggest that the client take brief showers and apply oil-based lotion after showering
D. Explain that the symptoms are caused by liver damage and cannot be relieved A. Encourage
the client to use cooler water and apply calamine lotion after soaking
An older client with a long history of coronary artery disease (CAD), hypertension (HTN), and
heart failure (HF) arrives in the Emergency Department (ED) in respiratory distress. The
healthcare provider prescribes furosemide IV. Which therapeutic response to furosemide should
the nurse expected in the client with acute HF?
A. Increased cardiac contractility
B. Reduced preload
,C. Relaxed vascular tone
D. Decreased afterload B. Reduced preload
A female client presents in the emergency department and tells the nurse that she was raped
last night. Which question is most important for the nurse to ask?
A. Has she taken a bath since the rape occurred?
B. Is the place where she lives a safe place?
C. Does she know the person who raped her?
D. Did she report the rape to the police department? A. Has she taken a bath since the
rape occurred?
The nurse is completing the admission assessment of a 3-year-old who is admitted with
bacterial meningitis and hydrocephalus. Which assessment finding is evidence that the child is
experiencing increased intracranial pressure (ICP)?
A. Tachycardia and tachypnea
B. Sluggish and unequal pupillary responses
C. Increased head circumference and bulging fontanels
D. Blood pressure fluctuations and syncope B. Sluggish and unequal pupillary responses
, A client with acute pancreatitis is admitted with severe, piercing abdominal pain and an
elevated serum amylase. Which additional information is the client most likely to report to the
nurse?
A. Abdominal pain decreases when lying supine
B. Pain lasts an hour and leaves the abdomen tender
C. Right upper quadrant pain refers to right scapula
D. Drinks alcohol until intoxicated at least twice weekly. A. Abdominal pain decreases when
lying supine
A child newly diagnosed with sickle cell anemia (SCA) is being discharged from the hospital.
Which information is most important for the nurse to provide the parents prior to discharge?
A. Instructions about how much fluid the child should drink daily.
B. Signs of addiction to opioid pain medications
C. Information about non-pharmaceutical pain relief measures
D. Referral for social services for the child and family A. Instructions about how much fluid
the child should drink daily