A nurse is caring for a client who had abdominal surgery 24 hours ago. Which of the

following actions is the priority?

A. Assess fluid intake every 24 hours

B. Ambulate three times a day

C. Assist with deep breathing and coughing

D. Monitor the incision site for findings of infection

{{Correct Ans- C

The priority action the nurse should take when using the airway, breathing, circulation

approach to client care is to assist the client with deep breathing and coughing, which

reduces the risk for postoperative pneumonia.

A nurse is talking with a client who has stage IV breast cancer. The nurse should

recognize which of the following statements by the client as a constructive use of a

defense mechanism?

A. I have experienced physical discomfort when intimate with my partner since my

diagnosis

B. I wish other women would stop socializing with my partner

C. I told my doctor that I would like to start a support group for other women who are

sick in my community

D. I used to mistrust my doctor, but now I know that she is the best one to care for me

during my illness

{{Correct Ans- C

This statement indicates that the client is using the constructive defense mechanism

sublimation by devising a socially acceptable alternative to facing a reality that she

does not wish to accept.

A nurse is caring for a client who has immunosuppression and a continuous IV

infusion. Which of the following actions should the nurse take?

A. Assess the clients IV site every 8 hours

B. Check the clients WBC count every 48 hours

C. Monitor the clients mouth every 8 hours

D. Change the clients IV tubing every 48 hours