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To help minimize the risk of postoperative respiratory complications after a hypophysectomy, during preoperative teaching, the nurse should instruct the client how to:
- A. Use incentive spirometry.
- B. Turn in bed.
- C. Take deep breaths.
- D. Cough.
Correct Answer: C
Rationale: The correct answer is to instruct the client on how to take deep breaths. Deep breathing exercises are essential in preventing postoperative respiratory complications like atelectasis by promoting lung expansion. Using incentive spirometry is a more specific and advanced method of promoting deep breathing and lung expansion, making it a better choice than just turning in bed. While turning in bed may help with overall comfort and positioning, it is not as directly related to respiratory complications as deep breathing exercises. Coughing, although important for clearing secretions, is not as effective in preventing atelectasis as deep breathing exercises.
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A client has had a pulmonary artery catheter inserted. In performing hemodynamic monitoring with the catheter, the nurse will wedge the catheter to gain information about which of the following?
- A. Cardiac output.
- B. Right atrial blood flow.
- C. Left end-diastolic pressure.
- D. Cardiac index.
Correct Answer: C
Rationale: The correct answer is C: Left end-diastolic pressure. Wedging the pulmonary artery catheter allows the nurse to obtain the pulmonary artery wedge pressure, which reflects the left end-diastolic pressure. This pressure is essential in assessing left ventricular function and diagnosing conditions like heart failure. Choices A, B, and D are incorrect because wedging the catheter does not directly provide information about cardiac output, right atrial blood flow, or cardiac index.
A young adult is burned when wearing a shirt that was splashed with lighter fluid and caught on fire while attempting to light a charcoal grill. The client ripped off the shirt immediately, without unbuttoning the sleeves, which caused circumferential burns to both wrists. When the client is admitted, which intervention should the nurse implement first?
- A. Monitor pulse intensity.
- B. Evaluate extremity sensation.
- C. Assess range of motion.
- D. Place sterile bandage on both wrists.
Correct Answer: A
Rationale: Monitoring pulse intensity is the priority to ensure circulation is not compromised due to circumferential burns.
The healthcare provider is developing standards of care for a client with gastroesophageal reflux disease and wants to review current evidence for practice. Which one of the following resources will provide the most helpful information?
- A. A review in the Cochrane Library.
- B. A literature search in a database, such as the Cumulative Index to Nursing and Allied Health Literature (CINAHL).
- C. An online nursing textbook.
- D. The policy and procedure manual at the healthcare agency.
Correct Answer: A
Rationale: The Cochrane Library provides systematic reviews of primary research in healthcare, making it a reliable resource for evidence-based practice. Choice B, a literature search in a database like CINAHL, may also be useful but does not guarantee the same level of systematic review and reliability as the Cochrane Library. Choice C, an online nursing textbook, may offer information but might not provide the most current or evidence-based practices. Choice D, the policy and procedure manual at the healthcare agency, is unlikely to offer the comprehensive evidence-based information needed for developing standards of care.
In a patient with liver cirrhosis, which of the following lab results would be expected?
- A. Increased bilirubin levels.
- B. Decreased albumin levels.
- C. Increased liver enzymes.
- D. Decreased platelet count.
Correct Answer: A
Rationale: In a patient with liver cirrhosis, increased bilirubin levels would be expected. Liver cirrhosis leads to impaired liver function, causing a decrease in the liver's ability to process bilirubin, leading to its accumulation in the blood. This results in elevated bilirubin levels. Decreased albumin levels (choice B) may occur in liver cirrhosis due to impaired liver synthesis of proteins, but it is not as specific as increased bilirubin levels. Increased liver enzymes (choice C) can be seen in liver damage but are not as characteristic as elevated bilirubin levels. Decreased platelet count (choice D) can occur in liver cirrhosis due to hypersplenism, but it is not as specific as increased bilirubin levels in this context.
A client arrived to the medical-surgical unit 4 hours after a transurethral resection of the prostate (TURP). A triple-lumen catheter for continuous bladder irrigation with normal saline is infusing, and the nurse observes dark, pink-tinged outflow with blood clots in the tubing and collection bag. Which action should the nurse take?
- A. Monitoring catheter drainage
- B. Decreasing the flow rate
- C. Irrigating the catheter manually
- D. Discontinuing infusing the solution
Correct Answer: C
Rationale: In this scenario, the nurse should choose option C - irrigating the catheter manually. This action can help clear the clots from the catheter and ensure proper bladder drainage. Monitoring catheter drainage (option A) alone may not address the issue of clots obstructing the flow. Decreasing the flow rate (option B) could potentially worsen clot formation. Discontinuing the infusing solution (option D) without addressing the clots first may lead to inadequate irrigation and increase the risk of complications.