102.

Which nursing interventions would be a priority in preventing

complications after a cesarean birth?
1.
2.
3.
4.

Turn, cough, and deep breathe.

Limit fluid intake.
Supply a high-carbohydrate diet.
Evaluate skin integrity.

Strategy: Answers are implementations. Determine the outcome of each

answer choice. Is it desired?
(1) correctrepresents preventive care for respiratory congestion resulting from
anesthesia and shallow respirations due to the abdominal incision
(2) fluids should be encouraged
(3) will not prevent complications
(4) does not address a common complication
103. The nurse is caring for a client who has just returned to the
postsurgical unit following abdominal surgery for cancer of the colon. It is
MOST appropriate for the nurse to take which of the following actions?
1.
2.
3.
4.

Determine the stage of loss and grief.

Analyze the quality and quantity of pain.
Instruct the client to cough and deep breathe.
Ask the client to lift his head off the pillow.

Strategy: Answers are a mix of assessments and implementations. Does this

situation require assessment? Yes. Remember Maslow.
(1) physical needs take priority
(2) not most important
(3) implementation, should first assess
(4) correctshould assess whether there are any remaining effects of neuromuscular
blocking agents; may block ability to breathe deeply
104. A nurse recognizes that an initial positive outcome of treatment for a
victim of sexual abuse by one parent would be that the client
1.
2.
3.
4.

acknowledges willing participation in an incestuous relationship.

reestablishes a trusting relationship with his/her other parent.
verbalizes that s/he is not responsible for the sexual abuse.
describes feelings of anxiety when speaking about sexual abuse.

Strategy: Think about each answer choice.

(1) continues the myth of badness and that s/he deserved the abuse and actively
consented to it
(2) outcome that would be positive but usually is not an initial result of treatment
(3) correctvictim needs assistance to challenge belief of victims, which includes I
am bad and deserve the abuse
(4) expected outcome