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Questions 149

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Question 1 of 5

A nurse is giving instructions to parents of a child who had a tonsillectomy. Which instruction is the most important?

Correct Answer: C

Rationale: Avoiding straws prevents suction that could dislodge clots and cause bleeding, a critical post-tonsillectomy precaution.

Question 2 of 5

The nurse is caring for a client 7 days post-burn injury with 60% body surface area involved. The nursing care of this client would primarily focus on:

Correct Answer: A

Rationale: At 7 days post-burn, infection is a major risk due to open wounds and immunosuppression, making meticulous infection control the primary focus.

Question 3 of 5

One week after discharge of a postpartum client, the client's husband calls the postpartum unit and asks the nurse, 'Is it normal for my wife to cry at the drop of a hat? I'm worried I've done something to upset her.' The nurse's best initial response would be:

Correct Answer: B

Rationale: Postpartum blues are common within the first two weeks, characterized by emotional lability. Reassuring the husband while acknowledging the normalcy of this condition is appropriate.

Question 4 of 5

A nurse is caring for a client with a myocardial infarction. The nurse recognizes that the most common complication in the client following a myocardial infarction is:

Correct Answer: B

Rationale: Cardiac dysrhythmias are the most common complication following a myocardial infarction due to ischemia affecting the heart's electrical conduction system, leading to arrhythmias like ventricular tachycardia or fibrillation.

Question 5 of 5

The nurse has received report on the day's assigned clients. Which of the following clients should the nurse see first?

Correct Answer: C

Rationale: The client post-atrial fibrillation ablation with agitation, tachycardia (HR 130), hypotension (BP 90/50), and low urine output (30 cc in 2 hours) indicates potential instability, requiring immediate assessment. This takes priority over stable post-op pain, an IV with remaining fluid, or gastric distress.

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