Nokea
The nurse is caring for a client who is 2 days postoperative following abdominal surgery. The client reports pain at the incision site and a small amount of purulent drainage is noted. What is the most appropriate nursing action?
- A. Apply a sterile dressing to the incision.
- B. Reinforce the dressing and document the findings.
- C. Remove the dressing and assess the incision site.
- D. Notify the healthcare provider.
Correct Answer: D
Rationale: The correct answer is to notify the healthcare provider. Purulent drainage at the incision site is concerning as it may indicate an infection. The healthcare provider needs to be informed promptly to initiate appropriate treatment. Applying a sterile dressing (Choice A) may not address the underlying issue of infection. Reinforcing the dressing and documenting findings (Choice B) is important but should be preceded by notifying the healthcare provider. Removing the dressing and assessing the incision site (Choice C) may disturb the area and should be done under the guidance of the healthcare provider.
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The nurse is assessing a client with chronic obstructive pulmonary disease (COPD) who is receiving supplemental oxygen. Which laboratory value is most concerning?
- A. Serum sodium of 135 mEq/L
- B. Serum potassium of 4.0 mEq/L
- C. Serum bicarbonate of 18 mEq/L
- D. Serum glucose of 300 mg/dL
Correct Answer: C
Rationale: A serum bicarbonate level of 18 mEq/L is most concerning in a client with COPD as it indicates metabolic acidosis, requiring immediate intervention. In COPD, patients often retain carbon dioxide, leading to respiratory acidosis. A low serum bicarbonate level suggests that the body is compensating for this respiratory acidosis by increasing bicarbonate levels to maintain balance. Therefore, a low serum bicarbonate level in this scenario is alarming. Choices A, B, and D are within normal ranges and not directly related to the acid-base imbalance seen in COPD.
A client with a tracheostomy has thick, tenacious secretions. Which intervention should the nurse include in the plan of care?
- A. Encourage the client to drink plenty of fluids.
- B. Perform deep suctioning every 2 to 4 hours.
- C. Increase humidity in the client's room.
- D. Administer a mucolytic agent.
Correct Answer: C
Rationale: Increasing humidity in the client's room can help liquefy thick secretions and facilitate easier airway clearance in a client with a tracheostomy. Encouraging the client to drink plenty of fluids can be beneficial for overall hydration but may not directly address thick secretions. Deep suctioning every 2 to 4 hours can be harmful and cause trauma to the airway lining. Administering a mucolytic agent should be done under the healthcare provider's order and may not be the initial intervention for thick secretions.
A male client is having abdominal pain after a left femoral angioplasty and stent, and is asking for additional pain medication for right lower quadrant pain (9/10). Two hours ago, he received hydrocodone/acetaminophen 7.5/325 mg. His vital signs are elevated from previous readings: temperature 97.8°F, heart rate 102 beats/minute, respiration 20 breaths/minute. His abdomen is swollen, the groin access site is tender, peripheral pulses are present, but the left is greater than the right. What data is needed to make this report complete?
- A. Client's lungs are clear bilaterally, and oxygen saturation is 97%.
- B. Surgeon needs to see the client immediately to evaluate the situation.
- C. Left peripheral pulses were present only by Doppler pre-procedure.
- D. Client's history includes multiple back surgeries and chronic pain.
Correct Answer: B
Rationale: The correct answer is B. In this scenario, the client is experiencing abdominal pain after a left femoral angioplasty and stent, with signs of potential complications such as a swollen abdomen, tenderness at the groin access site, and unequal peripheral pulses. The client's vital signs are also elevated, indicating a worsening condition. Given these findings, the immediate evaluation by the surgeon is crucial to assess for serious complications like internal bleeding or ischemia. Choice A is incorrect as the focus should be on the urgent need for surgical evaluation rather than lung sounds and oxygen saturation. Choice C is irrelevant to the immediate management of the client's current situation. Choice D, while providing background information, is not essential for the urgent intervention required in this case.
The nurse is assessing a client with left-sided heart failure. Which assessment finding requires immediate intervention?
- A. Jugular venous distention
- B. Shortness of breath
- C. Crackles in the lungs
- D. Peripheral edema
Correct Answer: C
Rationale: In a client with left-sided heart failure, crackles in the lungs are a critical assessment finding that necessitates immediate intervention. Crackles indicate pulmonary congestion, a sign of worsening heart failure that requires prompt attention to prevent respiratory distress. Jugular venous distention, shortness of breath, and peripheral edema are also common in heart failure, but crackles specifically point to pulmonary involvement and the urgent need for intervention.
Following routine diagnostic tests, a client who is symptom-free is diagnosed with Paget's disease. Client teaching should be directed toward what important goal for this client?
- A. Maintain adequate cardiac output.
- B. Promote adequate tissue perfusion.
- C. Promote rest and sleep.
- D. Reduce the risk for injury.
Correct Answer: D
Rationale: In Paget's disease, bone remodeling is affected, leading to increased risk for fractures. Therefore, the primary goal of client teaching should focus on reducing the risk for injury. Choices A and B are not directly related to the primary concern of Paget's disease, which is bone fractures. Choice C, promoting rest and sleep, is important for overall health but is not the priority when considering the specific risks associated with Paget's disease.