Choice A rationale:
Notifying the surgeon of the temperature elevation is important, but it is not the nurse's priority. A temperature elevation after abdominal surgery could be a sign of infection, but the immediate action should be to assess the surgical incision for any signs of infection.
Choice B rationale:
Encouraging the client to drink more fluids is a good practice to maintain hydration and promote recovery after surgery. However, it is not the nurse's priority in this situation. The elevated temperature and potential infection take precedence over increasing fluid intake.
Choice C rationale:
This is the correct answer because the nurse's priority is to assess the surgical incision for signs of infection. An elevated temperature is a significant finding after surgery, and it may indicate a surgical site infection, which requires prompt assessment and intervention.
Choice D rationale:
Monitoring vital signs every 4 hours is an essential nursing intervention after surgery, but it is not the priority when the client has an elevated temperature and a recent surgical incision.
The nurse must first assess for signs of infection before proceeding with routine vital sign monitoring.

A. Maintain affected leg elevated on several pillows. B. Instruct the client to wiggle the toes once every 4 hr. C. Use a hair dryer to promote drying of the cast. D. Apply heat to the client's cast to provide pain relief.

Correct Answer is A

Explanation

Choice A rationale:

The nurse should maintain the affected leg elevated on several pillows to reduce swelling and promote venous return. Elevating the leg helps minimize edema, which can be beneficial for the healing process and overall comfort of the client.

Choice B rationale:

Instructing the client to wiggle the toes once every 4 hours is not necessary and may cause discomfort to the fractured tibia. Toe wiggling does not provide any significant benefit in this context and could potentially disrupt the healing process.

Choice C rationale:

Using a hair dryer to promote drying of the cast is not recommended. Applying heat to the fiberglass cast may alter its integrity and lead to uneven drying, potentially weakening the cast's support.

Choice D rationale:

Applying heat to the client's cast for pain relief is not advisable. Heat may also weaken the cast material and is unlikely to provide effective pain relief for a fractured tibia. Instead, the nurse should follow the prescribed pain management plan and use appropriate pain medications as ordered by the healthcare provider.

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A nurse is inspecting the skin of a client who has basal cell carcinoma. The nurse should identify which of the following lesion characteristics on the client's skin?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who had a surgical repair of an abdominal aortic aneurysm 3 days ago. The client's vital signs are temperature 38.3°C (100.9°F), heart rate 80/min, respirations 16/min, and blood pressure 128/76 mm Hg. Which of the following actions is the nurse's priority?

Correct Answer is C

Explanation

A nurse is caring for a client who had a fiberglass cast applied 30 min ago for a fractured tibia. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is teaching a client who has schizophrenia a new prescription for lurasidone. Which of the following information should the nurse include in the teaching?(Select all that apply.).

A nurse is providing teaching about health promotion activities for a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is assessing a client for manifestations of mild Alzheimer's disease. Which of the following findings should the nurse expect as an early indication of the disease?

A nurse is preparing to discharge a client who is postoperative following a total hip arthroplasty. Which of the following equipment should the nurse ensure that the client has available at home prior to discharge?

A nurse is assessing a group of clients. For which of the following clients should the nurse make a referral to palliative care?

A nurse is reviewing the laboratory results for four clients. Which of the following results is the priority for the nurse to report to the provider?

A nurse in an emergency department is caring for a client who is in a sickle cell crisis. Which of the following actions should the nurse take?(Select all that apply.).

A nurse is caring for a client who is receiving peritoneal dialysis. When caring for the client's dialysis catheter, which of the following actions should the nurse plan to take?