A 3 day post-operative client with a left knee replacement is reporting chills and nausea. Temperature:
100.8oF/38.2oC, pulse: 94, respiration: 28 and
... [Show More] blood pressure is 146/90. What is the nurse's best action?
1. Call the surgeon immediately.
2. Administer extra strength acetaminophen per prescription.
3. Assess the surgical site.
4. Offer extra blankets and increase fluids.: 1. Correct: The client's symptoms are indicative of infection, and the
primary healthcare provider needs to be notified and may want diagnostic tests performed. The other actions are
appropriate to treat the symptoms and provide comfort, but they are not the best action to fix the problem.
2. Incorrect: While this may be appropriate, it may also delay treatment of the problem, which is infection. Remember, you
can only pick one answer to fix the problem and this action will only treat the symptoms.
3. Incorrect: The primary healthcare provider may want the site assessed, but this also delays treatment. Since you can
only pick one option, this is not the best.
4. Incorrect: Comfort measures are always appropriate, but this is not the best action available.
2.A 3-year-old child refuses to take a prescribed medication. Which statements by the mother, regarding the child's
refusal, indicate to the nurse that parental education is needed?
1. "My child is trying to make me angry".
2. "I feel like such a bad mother when my child acts this way".
3. "I promise my child a reward for taking medicine".
4. "I am unfazed by my child's actions".
5. "My child doesn't have to take medicine if he doesn't want to".: 1., 2. & 5. Correct: If the mother feels the child is
trying to "make her angry" she may respond with inappropriate discipline. The nurse can help the mother understand that
developing independence is one of the developmental tasks of a child this age, and that the movement toward
independence reflects good, not bad, parenting. The child must take the prescribed medicine in order to get well.
3. Incorrect: Rewarding the client for taking medication is not contraindicated.
4. Incorrect: Being "unfazed" by the child's actions does not reflect bad parenting.
Option 1 is true. The nurse needs to educate the parent.
Option 2 is true. The nurse needs to educate the parent regarding a 3 year old's typical behavior.
Option 3 is false, as further teaching would not be necessary if the parent made this statement.
Option 4 is false, as further teaching would not be necessary if the parent made this statement.
Option 5 is true. The child needs the medication or it would not have been prescribed. [Show Less]