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The nurse is caring for a client who will be taught to ambulate with a cane. Before cane-assisted ambulation instructions begin, what should the nurse check for as the priority to assure client safety?
- A. A high level of stamina and energy
- B. Self-consciousness about using a cane
- C. Full range of motion in lower extremities
- D. Balance, muscle strength, and confidence
Correct Answer: D
Rationale: Assessing the client's balance, strength, and confidence helps determine if the cane is a suitable assistive device for the client. A high level of stamina and full range of motion are not needed for walking with a cane. Although body image (self-consciousness) is a component of the assessment, it is not the priority.
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The nurse is scheduling a client for a series of diagnostic studies of the gastrointestinal (GI) system. Which of these studies should the nurse schedule last to avoid altering the results of the remaining tests?
- A. Ultrasound
- B. Colonoscopy
- C. Barium enema
- D. Computed tomography
Correct Answer: C
Rationale: When barium is instilled into the lower GI tract, it may take up to 72 hours to clear the GI tract. The presence of barium could cause interference with obtaining clear visualization and accurate results of the other tests listed if performed before the client has fully excreted the barium. For this reason, diagnostic studies that involve barium contrast are scheduled at the conclusion of other medical imaging studies.
A client has just undergone an upper gastrointestinal (GI) series. Upon the client's return to the unit, what primary health care provider's prescriptions does the nurse expect to note as a part of routine postprocedure care?
- A. Bland diet
- B. NPO status
- C. Mild laxative
- D. Decreased fluids
Correct Answer: C
Rationale: Barium sulfate, which is used as a contrast material during an upper GI series, is constipating. If it is not eliminated from the GI tract, it can cause obstruction. Therefore, laxatives or cathartics are administered as part of routine postprocedure care. Increased (not decreased) fluids are also helpful but do not act in the same way as a laxative to eliminate the barium.
The nurse instructs a preoperative client about the proper use of an incentive spirometer. What result should the nurse use to determine that the client is using the incentive spirometer effectively?
- A. Cloudy sputum
- B. Shallow breathing
- C. Unilateral wheezing
- D. Productive coughing
Correct Answer: D
Rationale: Incentive spirometry helps reduce atelectasis, open airways, stimulate coughing, and help mobilize secretions for expectoration, via vital client participation in recovery. Cloudy sputum, shallow breathing, and wheezing indicate that the incentive spirometry is not effective because they point to infection, counterproductive depth of breathing, and bronchoconstriction, respectively.
The nurse in the postpartum unit is assessing for signs of breast-feeding problems demonstrated by either the newborn or the mother. Which findings indicate a problem? Select all that apply.
- A. The infant exhibits dimpling of the cheeks.
- B. The infant makes smacking or clicking sounds.
- C. The mother's breast gets softer during a feeding.
- D. Milk drips from the mother's breast occasionally.
- E. The infant falls asleep after feeding less than 5 minutes.
- F. The infant can be heard swallowing frequently during a feeding.
Correct Answer: A,B,E
Rationale: Infant signs of breast-feeding problems include dimpling of the cheeks; making smacking or clicking sounds; falling asleep after feeding less than 5 minutes; refusing to breast-feed; tongue thrusting; failing to open the mouth at latch-on; turning the lower lip in; making short, choppy motions of the jaw; and not swallowing audibly. Softening of the breast during feeding, noting milk in the infant's mouth or dripping from the mother's breast occasionally, and hearing the infant swallow are signs that the infant is receiving adequate nutrition.
The nurse is caring for a client who has undergone transsphenoidal surgery for a pituitary adenoma. In the postoperative period, which information should the nurse provide to the client to minimize the risk for surgery-related injury?
- A. Cough and deep breathe hourly.
- B. Nasal packing will be removed after 48 hours.
- C. Report frequent swallowing or postnasal drip.
- D. Acetaminophen is prescribed for severe postsurgical headache.
Correct Answer: C
Rationale: The client should report frequent swallowing or postnasal drip or nasal drainage after transsphenoidal surgery because it could indicate cerebrospinal fluid (CSF) leakage. The client should deep breathe, but coughing is contraindicated because it could cause increased intracranial pressure. The surgeon removes the nasal packing placed during surgery, usually after 24 hours. The client should also report severe headache because it could indicate increased intracranial pressure.