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1. A nurse is planning care for a school-age child who is 4 hr postoperative following perforated appendicitis. Which of the following actions should the nurse include in the plan of care?
- A. Offer small amounts of clear liquids 6 hr following surgery.
- B. Give cromolyn nebulizer solution every 6 hr.
- C. Apply a warm compress to the operative site every 4 hr.
- D. Administer analgesics on a scheduled basis for the first 24 hr.
Correct answer: D
Rationale: Administering analgesics on a scheduled basis for the first 24 hours is crucial to ensure adequate pain control in the immediate postoperative period. Choice A is incorrect because clear liquids are typically initiated gradually and advanced as tolerated but not specifically at 6 hours post-surgery. Choice B is incorrect as cromolyn nebulizer solution is not indicated for postoperative pain management in this scenario. Choice C is incorrect as applying a warm compress may not be appropriate for the operative site after appendicitis surgery and can potentially increase the risk of infection.
2. A client who is 1 day postoperative following a total hip arthroplasty should be instructed to do which of the following?
- A. Avoid using a walker while walking.
- B. Keep the hip flexed at 90° while sitting.
- C. Place a pillow between your legs when turning.
- D. Cross your legs at the ankles when sitting.
Correct answer: C
Rationale: Placing a pillow between the legs is essential post-total hip arthroplasty to prevent adduction of the hip joint, reducing the risk of dislocation. Choices A, B, and D are incorrect. Using a walker while walking is encouraged for support and stability. Keeping the hip flexed at 90° while sitting can increase the risk of hip dislocation. Crossing legs at the ankles when sitting may also lead to hip dislocation.
3. A nurse is collecting data from a newly-admitted infant who is 3 months old and has diarrhea. Which of the following findings should the nurse report to the provider?
- A. Weight gain
- B. Poor appetite
- C. Irritability
- D. Decreased urination
Correct answer: C
Rationale: Irritability in infants can indicate worsening dehydration, which needs to be reported. Weight gain (Choice A) would be a positive finding, indicating adequate fluid intake. Poor appetite (Choice B) is common with diarrhea but not as concerning as irritability. Decreased urination (Choice D) can also be a sign of dehydration, but irritability is more specific to worsening dehydration in this case.
4. How should a healthcare professional assess a patient with chest pain?
- A. Assess the severity of pain and monitor ECG
- B. Administer nitroglycerin and provide oxygen
- C. Administer aspirin and provide pain relief
- D. Monitor for nausea and administer IV fluids
Correct answer: A
Rationale: When assessing a patient with chest pain, the initial step is to assess the severity of pain and monitor the electrocardiogram (ECG) to look for signs of cardiac issues. Administering nitroglycerin and oxygen (Choice B) is a treatment option for suspected cardiac chest pain but should not precede a thorough assessment. Administering aspirin and providing pain relief (Choice C) may be indicated later, but the priority is to assess the situation first. Monitoring for nausea and administering IV fluids (Choice D) is not the initial assessment for chest pain unless there are specific indications present.
5. What are the differences between viral and bacterial infections?
- A. Viral infections often cause fatigue and body aches
- B. Bacterial infections often cause high fever and localized pain
- C. Viral infections are treated with antibiotics
- D. Bacterial infections are usually self-limiting
Correct answer: A
Rationale: Corrected Rationale: Viral infections often cause fatigue and body aches, while bacterial infections are more likely to cause high fever and localized pain. Choice A is the correct answer as it accurately reflects the symptoms commonly associated with viral infections. Bacterial infections, on the other hand, typically present with fever and localized pain, as stated in choice B. Choice C is incorrect as viral infections do not respond to antibiotics, while choice D is inaccurate because bacterial infections may require antibiotic treatment and are not always self-limiting.
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