Question

A nurse is assessing a child who is postoperative following a tonsillectomy. Which of the following findings should the nurse identify as the priority?

Answer 1

Correct Answers:

Frequent swallowing

Rationale :

🟥 Frequent swallowing may indicate active bleeding at the surgical site, a major post-tonsillectomy complication.

🟥 Children often swallow blood rather than spit it out, making it a subtle but critical indicator.

🟥 Hemorrhage risk is highest within the first 24 hours postoperatively.

🟥 Prompt recognition of this sign enables immediate intervention to prevent shock.

🟥 This sign takes priority over normal findings like sore throat or blood-tinged mucus.

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Answer 2

Correct Answers:

Herpes zoster

Rationale :

🟩 The zoster vaccine is recommended for adults age 50 and older to prevent shingles.

🟩 Older adults have a declining immune system, increasing their risk.

🟩 This vaccine reduces the chance of postherpetic neuralgia, a painful complication.

🟩 The other options are intended for children or adolescents, not older adults.

🟩 Community health education should reflect age-appropriate vaccination schedules.

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Answer 3

Correct Answers:

Underweight

Rationale :

🟦 A BMI of 17.2 falls under the classification of underweight (<18.5).

🟦 Clients with Crohn’s disease commonly have malabsorption, leading to weight loss.

🟦 This puts them at risk for nutrient deficiencies, fatigue, and muscle wasting.

🟦 Monitoring BMI is essential to evaluate nutritional status and disease progression.

🟦 Early identification allows for dietary interventions and possibly TPN.

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Answer 4

Correct Answers:

Veracity

Rationale :

🟨 Veracity refers to the nurse’s duty to provide truthful information to clients.

🟨 The nurse's statement about lightheadedness and lack of memory loss shows honesty.

🟨 Promoting trust through accurate education enhances informed consent.

🟨 This ethical principle fosters transparency and supports client autonomy.

🟨 Veracity is essential in mental health settings to maintain therapeutic rapport.

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Answer 5

Correct Answers:

Activate the fire alarm system.

Rationale :

🟥 According to the RACE protocol, the first step is to Rescue, then Alarm.

🟥 Activating the alarm alerts other staff and fire response systems.

🟥 It's crucial for coordinated evacuation and suppression.

🟥 Fire extinguishers or evacuation come after alarm activation in many protocols.

🟥 Immediate communication reduces risk to all patients and staff.

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Answer 6

Correct Answers:

Position the client with her knees flexed and legs apart.

Rationale :

🟪 Proper positioning is the first physical step before catheter insertion.

🟪 Flexing the knees and spreading the legs provides access to the urethral meatus.

🟪 This ensures anatomical visibility and reduces contamination risk.

🟪 It sets the stage for a sterile procedure, which follows positioning.

🟪 Starting with positioning promotes client comfort and efficiency.

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Answer 7

Correct Answers:

"I know the provider will replace the lens in my eyes during this procedure."

Rationale :

🔷 Cataract surgery involves removal of the clouded lens and replacement with an artificial intraocular lens.

🔷 This statement reflects correct anatomical and procedural understanding.

🔷 Misconceptions about bruising or general anesthesia are common and should be corrected.

🔷 Understanding the procedure helps reduce anxiety and increases cooperation.

🔷 Preoperative teaching supports informed consent and realistic expectations.

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Answer 8

Correct Answers:

Repeat the complete prescription back to the provider.

Rationale :

🟨 Telephone orders should always be read back to the provider to ensure accuracy.

🟨 This step reduces risk of medication errors, especially with sound-alike drugs.

🟨 Verbal orders are prone to miscommunication, making confirmation critical.

🟨 It is a required step in safe medication practice protocols.

🟨 Documenting that the prescription was read back also provides legal protection.

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Answer 9

Correct Answers:

Instruct the client to use an overbed trapeze to move around in bed.

Rationale :

🟫 An overbed trapeze promotes independent mobility without putting pressure on the amputation site.

🟫 It prevents shearing and pressure injuries by facilitating upper body movement.

🟫 Early mobility reduces risks of atelectasis and DVT postoperatively.

🟫 Encouraging participation enhances client autonomy and strength.

🟫 This method is part of rehabilitation planning after lower extremity amputation.

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Answer 10

Correct Answers:

Measure the legs with a tape measure to determine stocking size.

Rationale :

🟩 Antiembolitic stockings must fit precisely to exert the correct pressure gradient.

🟩 Measuring ensures proper compression to prevent venous thromboembolism.

🟩 Ill-fitting stockings may cause constriction, discomfort, or skin injury.

🟩 Measurement should include length and circumference at multiple points.

🟩 Sizing promotes safe and effective DVT prevention.

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QLexNursing

1 :
A nurse is assessing a child who is postoperative following a tonsillectomy. Which of the following findings should the nurse identify as the priority?

2 :
A community health nurse is providing education to a group of older adults about immunizations. Which of the following immunizations should the nurse recommend?

3 :
A nurse is caring for a client who has Crohn's disease. The nurse calculates that the client's BMI is 17.2. The nurse should document the client's weight status as being within which of the following categories?

5 :
A charge nurse observes smoke coming from a trash receptacle in the unit's waiting room. Which of the following actions should the nurse take first?

6 :
A nurse is preparing to insert an indwelling urinary catheter for a female client. Which of the following actions should the nurse take first?

7 :
A nurse is caring for a client who is preoperative for cataract removal. Which of the following statements by the client indicates an understanding of the procedure?

8 :
A nurse on a medical-surgical unit is accepting a telephone prescription for a client who requires medication for insomnia. Which of the following actions should the nurse take?

9 :
A nurse is caring for a client who is 12 hr postoperative following a below-the-knee amputation. Which of the following interventions should the nurse implement?

10 :
A nurse is caring for a client who has deep-vein thrombosis and a new prescription for antiembolitic stockings. Which of the following actions should the nurse take?

QLexNursing

1 : A nurse is assessing a child who is postoperative following a tonsillectomy. Which of the following findings should the nurse identify as the priority?

2 : A community health nurse is providing education to a group of older adults about immunizations. Which of the following immunizations should the nurse recommend?

3 : A nurse is caring for a client who has Crohn's disease. The nurse calculates that the client's BMI is 17.2. The nurse should document the client's weight status as being within which of the following categories?

5 : A charge nurse observes smoke coming from a trash receptacle in the unit's waiting room. Which of the following actions should the nurse take first?

6 : A nurse is preparing to insert an indwelling urinary catheter for a female client. Which of the following actions should the nurse take first?

7 : A nurse is caring for a client who is preoperative for cataract removal. Which of the following statements by the client indicates an understanding of the procedure?

8 : A nurse on a medical-surgical unit is accepting a telephone prescription for a client who requires medication for insomnia. Which of the following actions should the nurse take?

9 : A nurse is caring for a client who is 12 hr postoperative following a below-the-knee amputation. Which of the following interventions should the nurse implement?

10 : A nurse is caring for a client who has deep-vein thrombosis and a new prescription for antiembolitic stockings. Which of the following actions should the nurse take?

1 :
A nurse is assessing a child who is postoperative following a tonsillectomy. Which of the following findings should the nurse identify as the priority?

2 :
A community health nurse is providing education to a group of older adults about immunizations. Which of the following immunizations should the nurse recommend?

3 :
A nurse is caring for a client who has Crohn's disease. The nurse calculates that the client's BMI is 17.2. The nurse should document the client's weight status as being within which of the following categories?

5 :
A charge nurse observes smoke coming from a trash receptacle in the unit's waiting room. Which of the following actions should the nurse take first?

6 :
A nurse is preparing to insert an indwelling urinary catheter for a female client. Which of the following actions should the nurse take first?

7 :
A nurse is caring for a client who is preoperative for cataract removal. Which of the following statements by the client indicates an understanding of the procedure?

8 :
A nurse on a medical-surgical unit is accepting a telephone prescription for a client who requires medication for insomnia. Which of the following actions should the nurse take?

9 :
A nurse is caring for a client who is 12 hr postoperative following a below-the-knee amputation. Which of the following interventions should the nurse implement?

10 :
A nurse is caring for a client who has deep-vein thrombosis and a new prescription for antiembolitic stockings. Which of the following actions should the nurse take?