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Questions 176

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Extract:


Question 1 of 5

A client is being discharged after having a coronary artery bypass grafting x5. The client asks questions about the care of chest and leg incisions. Which instructions should the nurse reinforce? Select all that apply.

Correct Answer: A, B, D

Rationale: Reporting sensory changes (
A), signs of infection (
B), and washing gently (
D) promote healing. Soaking and peroxide (
C) can disrupt healing, and compression hose (E) are not routinely needed.

Question 2 of 5

Which finding by the nurse suggests that the mother is not giving the toddler iron supplements as ordered?

Correct Answer: B

Rationale: Iron supplements typically cause dark or black stools; light brown stools suggest non-compliance with iron supplementation.

Question 3 of 5

A 70 year-old post-operative client has elevated serum BUN, HCT, Cl, and Na+. Creatinine and K+ are within normal limits. The nurse should perform additional assessments to confirm that an actual problem is:

Correct Answer: D

Rationale: Fluid volume deficit. In fluid volume deficit, serum BUN, Na+, and hematocrit may be elevated secondary to hemoconcentration.

Question 4 of 5

The nurse has reinforced teaching with a client with newly diagnosed polycythemia vera. Which of the following statements by the client would require follow-up?

Correct Answer: A

Rationale: Iron supplements (
A) can worsen polycythemia vera by increasing red blood cell production, requiring follow-up. Increased fluids (
B), phlebotomy (
C), and aspirin (
D) are appropriate.

Question 5 of 5

The home health nurse visits a 72-year-old client with pneumonia who was discharged from the hospital 3 days ago. The client has less of a productive cough at night but now reports sharp chest pain with inspiration. Which finding is most important for the nurse to report to the supervising registered nurse?

Correct Answer: D

Rationale: Pleural friction rub (
D) indicates pleuritis or pleural effusion, a serious complication requiring immediate reporting. Other findings (A, B,
C) are less specific or urgent.

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