Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
Which of the following should the nurse recognize as a sign of possible infection in a postoperative client? (Select all that apply.)
A. Dry crust on the incision line
Dry crust on the incision line may indicate normal healing, not necessarily infection.
B. Adventitious breath sounds
Adventitious breath sounds can be indicative of pneumonia, a potential infection.
C. Increased urine output
Increased urine output is not a sign of infection but may suggest other issues.
D. Decreased level of consciousness
Decreased level of consciousness suggests a systemic issue, which could include infection affecting the central nervous system.
E. Oral temperature of 38.3° C (101° F)
Oral temperature of 38.3° C (101° F) indicates fever which is a common sign of infection.
This question is an excerpt from Nurse Dive's nursing test bank - Dumund ATI comprehensive med surg proctored exam. Take the full exam now
Full Explanation
A. Dry crust on the incision line may indicate normal healing, not necessarily infection.
B. Adventitious breath sounds can be indicative of pneumonia, a potential infection.
C. Increased urine output is not a sign of infection but may suggest other issues.
D. Decreased level of consciousness suggests a systemic issue, which could include infection affecting the central nervous system.
E. Oral temperature of 38.3° C (101° F) indicates fever which is a common sign of infection.
Similar Questions
A nurse at a provider’s office is reinforcing teaching with a client who is being treated with chemotherapy and is losing weight. Which of the following instructions should the nurse give to increase the client’s caloric intake? (Select all that apply.)
A. Use honey on toast.
Using honey on toast adds calories and sweetness.
B. Use milk instead of water in recipes.
Use milk instead of water in recipes increases the caloric content of the meal.
C. Increase fluids during meals.
While important for hydration, it does not directly increase caloric intake.
D. Substitute salad dressing for mayonnaise on sandwiches
Mayonnaise has more calories.
E. Top yogurt with granola.
None
Full Explanation
A. Using honey on toast adds calories and sweetness.
B. Use milk instead of water in recipes increases the caloric content of the meal.
C. While important for hydration, it does not directly increase caloric intake.
D. Mayonnaise has more calories.
E. Topping yogurt with granola adds calories and texture to increase caloric intake.
A nurse is contributing to the plan of care for a client who had a total joint replacement and is two days postoperative. Which of the following resources should the nurse consult to determine the client’s activity level for the day?
A. Critical pathway
Critical pathway provides a specific, timeline-based plan of care with expected outcomes and interventions, including activity levels.
B. Standards of care
Standards of care are important but may not offer specific guidance for the individual client's daily activity level.
C. Clinical practice guidelines
Guidelines may provide general recommendations but may lack specificity.
D. Textbook reference
This is general information source but not as specific or current as the institution's critical pathway.
Full Explanation
A. Critical pathway provides a specific, timeline-based plan of care with expected outcomes and interventions, including activity levels.
B. Standards of care are important but may not offer specific guidance for the individual client's daily activity level.
C. Guidelines may provide general recommendations but may lack specificity.
D. This is general information source but not as specific or current as the institution's critical pathway.
A nurse is reinforcing teaching with a client who has rheumatoid arthritis. Which of the following statements by the client indicates understanding of the information?
A. I will schedule important tasks in the afternoon.
Scheduling important tasks in the afternoon is a good strategy for managing fatigue, it does not directly address pain relief.
B. I need to perform range-of-motion of my joints if I notice they are red.
Performing range-of-motion if joints are red may exacerbate inflammation and is not a recommended practice.
C. I should stop exercising if 1 experience any discomfort.
Stopping exercising if experiencing discomfort is essential to differentiate between normal discomfort and pain that may indicate potential harm. Continuing with mild discomfort may be appropriate.
D. I can use heat or cold to help relieve my pain
Both heat and cold applications can provide relief from rheumatoid arthritis pain and inflammation.
Full Explanation
A. Scheduling important tasks in the afternoon is a good strategy for managing fatigue, it does not directly address pain relief.
B. Performing range-of-motion if joints are red may exacerbate inflammation and is not a recommended practice.
C. Stopping exercising if experiencing discomfort is essential to differentiate between normal discomfort and pain that may indicate potential harm. Continuing with mild discomfort may be appropriate.
D. Both heat and cold applications can provide relief from rheumatoid arthritis pain and inflammation.