A client returns to the unit after a neck dissection. The surgeon placed a Jackson-Pratt drain in the wound. When assessing the wound drainage over the first 24 postoperative hours, what finding would prompt the nurse to notify the health care provider immediately?

A. Presence of small blood clots in the drainage

B. 60 mL of milky or cloudy drainage

C. Spots of drainage on the dressings surrounding the drain

D. 120 mL of serosanguinous drainage

Correct Answer: B
Rationale: Milky or cloudy drainage can indicate infection or lymphatic leakage, which requires immediate attention. This finding may suggest a serious complication post neck dissection, warranting prompt notification of the healthcare provider for further evaluation and intervention.

A 65-year-old female client arrives in the emergency department with shortness of breath and chest pain. The nurse accidentally administers 10 mg of morphine sulfate instead of the prescribed 4 mg. Later, the client's respiratory rate is 10 breaths/minute, oxygen saturation is 98%, and she states her pain has subsided. What is the legal status of the nurse?

• A. The nurse is guilty of negligence and will be sued.
• B. The client would not be able to prove malpractice in court.
• C. The nurse is protected by the Good Samaritan Act.
• D. The healthcare provider should have given the morphine sulfate dose.

Correct Answer: B
Rationale: The correct answer is B because, in this scenario, the client would not be able to prove malpractice in court. Despite the nurse administering a higher dose of morphine than prescribed, the client's respiratory rate, oxygen saturation, and pain relief indicate that no harm resulted from the error. Therefore, the client would not have legal grounds to pursue a malpractice case against the nurse.

A 9-year-old female client was recently diagnosed with diabetes mellitus. Which symptom will her parents most likely report?

• A. Refuses to eat her favorite meals at home.
• B. Drinks more soft drinks than previously.
• C. Voids only one or two times per day.
• D. Gained 10 pounds within one month.

Correct Answer: B
Rationale: The correct answer is B. Increased thirst and fluid intake, such as drinking more soft drinks than previously, is a common symptom of diabetes mellitus in children. This increased thirst is due to the body trying to eliminate excess sugar through urination, leading to dehydration and the need for more fluids. The other choices are less likely to be directly related to the diagnosis of diabetes mellitus in this scenario.

The client with newly diagnosed hypertension is being taught about lifestyle modifications. Which recommendation should be made?

• A. Increase your intake of saturated fats.
• B. Limit your alcohol intake to two drinks per day.
• C. Engage in at least 150 minutes of moderate exercise per week.
• D. Use table salt liberally to season your food.

Correct Answer: C
Rationale: Engaging in at least 150 minutes of moderate exercise per week is a key lifestyle modification recommended for individuals with hypertension. Regular exercise helps manage blood pressure, improve cardiovascular health, and overall well-being. It is important for the client to adopt a healthy lifestyle to control hypertension and reduce the risk of complications.

The nurse is administering sevelamer (RenaGel) during lunch to a client with end-stage renal disease (ESRD). The client asks the nurse to bring the medication later. The nurse should describe which action of RenaGel as an explanation for taking it with meals?

• A. Prevents indigestion associated with the ingestion of spicy foods.
• B. Binds with phosphorus in foods and prevents absorption.
• C. Promotes stomach emptying and prevents gastric reflux.
• D. Buffers hydrochloric acid and prevents gastric erosion.

Correct Answer: B
Rationale: Sevelamer (RenaGel) binds with phosphorus in foods to prevent its absorption, which is why it should be taken with meals. By taking RenaGel with meals, it can effectively bind with phosphorus from food, reducing the amount of phosphorus absorbed by the body, thus helping to manage hyperphosphatemia in clients with ESRD. Choices A, C, and D are incorrect because RenaGel's primary action is to bind with phosphorus in foods, not related to preventing indigestion, promoting stomach emptying, or buffering hydrochloric acid.