1. 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: 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.

2. 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: 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.

3. 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: C

4. A nurse is caring for a 2-month-old infant who has Hirschsprung disease

(HD). Which of the following areas should the nurse assess for manifestations of HD?

A. Eyes area