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

Explanation

Rationale:

A. Check for seals in the drainage system: Urinary leakage in a client with an indwelling catheter may indicate a break in the closed drainage system. Inspecting for disconnected or loose seals is essential to verify the system’s integrity and ensure proper catheter function, reducing the risk of backflow or infection.

B. Place a waterproof pad under the client's buttocks: This action addresses the symptom of leakage rather than identifying or correcting the cause. While it may help manage moisture, it does not ensure the catheter is functioning properly or prevent further complications.

C. Clip the drainage tubing to the edge of the mattress: Clipping the tubing can obstruct flow and increase the risk of urine retention or reflux. Tubing should be secured loosely and not kinked, with no tension that might disrupt drainage or lead to malfunction.

D. Position the drainage bag below the level of the client's bladder: While proper bag positioning is important to promote gravity drainage, it does not specifically verify safe functioning if leakage is occurring. Ensuring the drainage system is intact is the first step in evaluating catheter function.

A. Provide the caregiver with information on behavior therapy. B. Screen the child for depression prior to initiating the medication. C. Monitor liver function test results while the child is taking the medication D. Monitor the child for nightmares while taking the medication. E. Monitor the child's blood pressure at each visit.

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.

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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 is caring for a client who has an indwelling urinary catheter and reports urinary leakage. Which of the following actions should the nurse take to verify the safe functioning of the urinary catheter?

Correct Answer is A

Explanation

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

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