Adult Health 1 Exam 1

Correct Answer: C

Rationale: In this scenario, the correct intervention is to outline the area with ink and check it every 15 minutes to monitor for changes in bleeding. This approach helps in assessing the extent and progression of the bleeding. Option A is incorrect because assessing hemoglobin levels would not provide immediate information on the ongoing bleeding. Option B is premature without first monitoring the bleeding site. Option D is incorrect because although some postoperative bleeding can be expected, fresh bleeding on the cast warrants immediate monitoring and evaluation.

Correct Answer: A

Rationale: The correct first action for the nurse to take when a post-operative client complains of severe pain is to reassess the pain and its characteristics. Reassessment is crucial to understand the nature and intensity of the pain, which will guide the nurse in providing appropriate interventions. Administering pain medication may be necessary but should only be done after reassessment to ensure the right medication and dose are given. Notifying the surgeon may be required in certain situations, but reassessment of pain should precede this action. Encouraging relaxation techniques is not the priority when a client is experiencing severe pain post-operatively.

Correct Answer: B

Rationale: The correct response for the nurse in this situation is to ask for a description of what happened during the night. This allows the nurse to gather specific information about the care provided and address the complaint appropriately. Choice A is incorrect because dismissing the concern by stating that all staff are doing their best does not address the specific complaint. Choice C is not the best immediate response as the charge nurse should first gather information before escalating the issue to the nurse manager. Choice D is incorrect as it focuses on reassurance without addressing the reported issue.

Correct Answer: C

Rationale: After observing the client cough and produce frothy saliva in the collection cup, the nurse should provide the client with a glass of water and mouthwash to rinse the mouth. This action helps clear the mouth of contaminants, ensuring a more accurate sputum specimen for diagnostic testing. Option A is incorrect because suctioning is not the appropriate next step in this situation. Option B is unnecessary as re-instructing the client in coughing techniques may not address the immediate issue of contaminated saliva in the specimen. Option D is premature since labeling and transporting the container should only be done after obtaining a valid specimen.

Correct Answer: D

Rationale: The correct answer is to discontinue the IV infusion. Pain and swelling at the IV site may indicate infiltration or phlebitis, which requires immediate discontinuation of the infusion to prevent further complications. Continuing the infusion can lead to tissue damage or infection. Slowing the rate of infusion, applying a warm compress, or elevating the affected arm would not address the underlying issue of infiltration or phlebitis and could potentially worsen the condition by allowing more fluid to infiltrate the tissues.