A nurse is caring for a client who is 24 hours post-operative following a
cholecystectomy. Which of the following findings should the nurse
report to the healthcare provider immediately?
A. The client reports incisional pain
B. The client has a temperature of 101°F (38.3°C)
C. The client has an increased white blood cell count
D. The client has a small amount of clear drainage on the dressing
Answer: B. The client has a temperature of 101°F (38.3°C)
Rationale: A post-operative fever of 101°F (38.3°C) could indicate a
developing infection or a complication like a bile leak or abscess. This
requires prompt evaluation and intervention by the healthcare provider.
While mild pain and clear drainage are expected after surgery, a fever is
a concerning sign.
Question 2:
A nurse is assessing a client with hypertension who is prescribed a
calcium channel blocker. Which of the following findings should the
nurse report to the healthcare provider immediately?
A. The client has ankle edema
B. The client has a blood pressure reading of 150/90 mmHg
C. The client has a heart rate of 56 beats per minute
D. The client reports occasional dizziness when standing up
Answer: C. The client has a heart rate of 56 beats per minute
Rationale: A heart rate of 56 beats per minute in a client taking a
calcium channel blocker can be a sign of bradycardia, which is a
potential adverse effect of the medication. It requires immediate
,attention because it could lead to reduced cardiac output and
hypotension.
Question 3:
A nurse is caring for a client who is receiving an intravenous (IV)
infusion of normal saline at 100 mL/hr. The nurse notes that the
client’s infusion site is swollen and cool to the touch. What is the first
action the nurse should take?
A. Increase the rate of the IV infusion
B. Discontinue the IV infusion and remove the catheter
C. Apply a warm compress to the site
D. Elevate the client’s affected limb
Answer: B. Discontinue the IV infusion and remove the catheter
Rationale: The signs of swelling and coolness at the infusion site
suggest infiltration, where the IV fluid has leaked into the surrounding
tissue. The first action is to discontinue the IV and remove the catheter
to prevent further complications, such as tissue damage.
Question 4:
A nurse is caring for a client with type 1 diabetes mellitus. Which of
the following symptoms is most indicative of hypoglycemia?
A. Nausea and vomiting
B. Increased thirst and urination
C. Shaking and confusion
D. Flushed, dry skin
Answer: C. Shaking and confusion
, Rationale: Shaking and confusion are common symptoms of
hypoglycemia due to a drop in blood glucose levels. Other symptoms of
hypoglycemia can include sweating, dizziness, and irritability. Nausea
and vomiting, increased thirst, and dry skin are more commonly
associated with hyperglycemia.
Question 5:
A nurse is preparing to administer a scheduled dose of furosemide
(Lasix) to a client. The nurse reviews the client’s laboratory results and
notes that the potassium level is 3.0 mEq/L. What is the nurse’s next
action?
A. Administer the medication as ordered
B. Hold the medication and notify the healthcare provider
C. Encourage the client to eat potassium-rich foods
D. Give the medication with potassium supplements
Answer: B. Hold the medication and notify the healthcare provider
Rationale: A potassium level of 3.0 mEq/L is low, and administering
furosemide, a potassium-wasting diuretic, could exacerbate the
hypokalemia. The nurse should hold the medication and notify the
healthcare provider for further instructions.
Question 6:
A nurse is caring for a client who has recently started taking warfarin.
The nurse should monitor for which of the following laboratory values
to assess for potential complications?
A. Platelet count
B. Hemoglobin level