A nurse is collecting data for a client who is postoperative and has an elevated temperature. Which of the following actions should the nurse take first?

Assist the client with dangling off the side of the bed.

Check the condition of the client's surgical incision.

Instruct the client to breathe deeply and cough.

Obtain a prescription to check the client's CBC.

Answer and Explanation

The Correct Answer is B

Rationale:

A. Assist the client with dangling off the side of the bed: Early ambulation is important in the postoperative period to prevent complications such as atelectasis or deep vein thrombosis. However, it is not the first action when an elevated temperature is observed, as the cause of the fever must be assessed first.

B. Check the condition of the client's surgical incision: Inspecting the surgical site addresses a potential source of infection, which is a common cause of postoperative fever. This direct assessment helps determine whether local inflammation, drainage, or other signs of infection are present and guides further intervention.

C. Instruct the client to breathe deeply and cough: Encouraging deep breathing and coughing promotes lung expansion and reduces the risk of atelectasis and pneumonia, other causes of postoperative fever. While beneficial, checking the incision for infection is a more direct and immediate assessment for a common and serious cause of postoperative fever.

D. Obtain a prescription to check the client's CBC: A CBC can provide useful information on infection or inflammation, but obtaining lab orders should come after performing a focused assessment to gather immediate, observable data that may warrant urgent action.

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Free Nursing Study Resources

Correct Answer is ["A","C","D","E"]

Explanation

A.Provide the caregiver with information on behavior therapy: Behavior therapy is a first-line, evidence-based nonpharmacologic intervention for ADHD, particularly in children. Educating caregivers about behavioral strategies helps improve symptom management and supports long-term success.
B. Screen the child for depression prior to initiating the medication: Although screening for comorbid conditions like depression is important in ADHD management, it is typically part of the initial diagnostic workup, which was already completed with neurology and developmental evaluations.
C. Monitor liver function test results while the child is taking the medication: Atomoxetine carries a risk of rare but serious liver toxicity. Regular monitoring of liver function is essential during treatment, especially if the child shows signs of liver dysfunction (e.g., dark urine, abdominal pain, jaundice).
D. Monitor the child for nightmares while taking the medication: Sleep disturbances, including insomnia and nightmares, are known side effects of atomoxetine. Nurses should monitor and educate caregivers about possible changes in sleep behavior while the child is on this medication.
E.Monitor the child's blood pressure at each visit: Atomoxetine can cause increases in blood pressure and heart rate. Routine monitoring of vital signs at follow-up visits is necessary to ensure cardiovascular safety during treatment.

A. "This surgery can cause an increase in the amount of semen." B. "I will talk to my partner about other ways of expressing intimacy." C. “I will not be able to have sexual intercourse after this surgery." D. “This surgery will prevent me from being able to have an erection."

Correct Answer is B

Explanation

Rationale:

A. "This surgery can cause an increase in the amount of semen.":A transurethral resection of the prostate (TURP) often results in retrograde ejaculation, meaning semen may flow backward into the bladder. The volume of visible semen typically decreases, not increases, due to this common complication.

B. "I will talk to my partner about other ways of expressing intimacy.":This statement reflects healthy psychological adjustment and understanding of potential changes in sexual function following TURP. It shows emotional readiness to adapt to changes and maintain intimacy in ways beyond penetrative sex, which supports recovery and relationship stability.

C. “I will not be able to have sexual intercourse after this surgery.":TURP does not prevent sexual intercourse. While temporary issues like erectile dysfunction or retrograde ejaculation may occur, most clients can resume sexual activity after recovery. This belief represents a misunderstanding of surgical outcomes.

D. “This surgery will prevent me from being able to have an erection.": Although some men may experience temporary erectile dysfunction postoperatively, TURP typically does not cause permanent loss of erectile function. Misconceptions about impotence should be addressed through accurate education.

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A nurse is collecting data for a client who is postoperative and has an elevated temperature. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a pediatric office is assisting in the care of a child. Exhibits A nurse is contributing to the plan of care for a child. Which of the following interventions should the nurse recommend? Select the 4 interventions the nurse should recommend for the child's plan of care.

Correct Answer is ["A","C","D","E"]

Explanation

A nurse is reinforcing teaching with a client who is postoperative following a transurethral resection of the prostate. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is B

Explanation

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