Nokea
A 3-day post-operative client with a Left Knee Replacement is complaining of being chilled and nauseated. Her TPR is 100.4-94-28 and Blood Pressure is 146/90. What is the nurse's best action?
- A. Call the surgeon immediately.
- B. Administer Extra Strength Tylenol per orders.
- C. Assess the surgical site.
- D. Offer extra blankets and increase fluids.
Correct Answer: A
Rationale: The correct answer is to call the surgeon immediately. The client's symptoms of being chilled and nauseated, along with an elevated temperature (100.4°F), could indicate an infection following the knee replacement surgery. In this scenario, prompt action is crucial to prevent any potential complications. Calling the surgeon allows for further assessment, possible diagnostic tests, and appropriate interventions to be initiated. Administering Tylenol or offering blankets and fluids may temporarily alleviate symptoms but do not address the underlying issue of a potential infection. Assessing the surgical site is important but not as urgent as involving the surgeon in this situation.
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After a left heart catheterization (LHC), a client complains of severe foot pain on the side of the femoral stick. The nurse notes pulselessness, pallor, and a cold extremity. What should the nurse's next action be?
- A. Administer an anticoagulant.
- B. Warm the room and re-assess.
- C. Increase IV fluids.
- D. Notify the physician stat.
Correct Answer: D
Rationale: The correct action for the nurse to take next is to notify the physician immediately (stat). The client's symptoms of foot pain, pulselessness, pallor, and cold extremity suggest a potential vascular complication, such as arterial occlusion. Prompt notification of the physician is crucial as this condition requires urgent intervention to restore blood flow and prevent tissue damage. Administering an anticoagulant (Choice A) without physician evaluation could be harmful as the underlying cause needs to be determined first. Warming the room and re-assessing (Choice B) may delay necessary treatment. Increasing IV fluids (Choice C) is unlikely to address the urgent vascular issue indicated by the symptoms described.
The charge nurse on a cardiac unit tells you a patient is exhibiting signs of right-sided heart failure. Which of the following would not indicate right-sided heart failure?
- A. Muscle tetany
- B. Syncope
- C. Numbness
- D. Anxiety
Correct Answer: D
Rationale: The correct answer is 'Anxiety.' Anxiety is not a typical sign of right-sided heart failure. Right-sided heart failure usually presents with symptoms such as muscle tetany, syncope, and numbness. Muscle tetany can occur due to electrolyte imbalances seen in heart failure. Syncope can result from decreased cardiac output, leading to decreased perfusion to the brain. Numbness can occur due to poor circulation. While anxiety can be present in patients with various medical conditions, it is more commonly associated with respiratory acidosis or other psychological factors rather than right-sided heart failure.
What should the nurse do while caring for a client with an eating disorder?
- A. Encourage the client to cook for others
- B. Weigh the client daily and keep a journal
- C. Restrict access to mirrors
- D. Monitor food intake and behavior for one hour after meals
Correct Answer: D
Rationale: The correct answer is to monitor food intake and behavior for one hour after meals. This is crucial in caring for a client with an eating disorder as it helps in assessing any immediate risks related to the disorder. Option A is incorrect as it may trigger additional stress for the client and distract from the main focus of managing the disorder. Option B, weighing the client daily, could lead to an unhealthy focus on weight and potentially worsen the client's mental health. Option C, restricting access to mirrors, although it may be beneficial for body image concerns, does not directly address the core issue of monitoring food intake and behavior, which is essential in managing eating disorders.
A patient has been prescribed Tegretol for the first time. Which of the following side effects is not associated with Tegretol?
- A. Sore throat
- B. Vertigo
- C. Fever
- D. Shortness of breath
Correct Answer: D
Rationale: The correct answer is 'Shortness of breath.' Side effects commonly associated with Tegretol include sore throat, vertigo, and fever. Shortness of breath is not a typical side effect of Tegretol use. Sore throat, vertigo, and fever are known side effects of Tegretol, while shortness of breath is not typically linked to its use.
The nurse observes a nursing assistant performing AM care for a client with a new leg cast. Which action by the assistant will the nurse intervene?
- A. Lifting the affected leg with the palms of the hands
- B. Covering the affected leg with a blanket to avoid chills
- C. Placing plastic over the groin prior to bathing
- D. Elevating the casted leg on two pillows
Correct Answer: B
Rationale: The correct answer is to intervene when the assistant covers the affected leg with a blanket to avoid chills. A new cast should not be covered to allow the heat from the cast to evaporate, preventing complications. Lifting the affected leg with the palms of the hands is appropriate for proper handling. Placing plastic over the groin prior to bathing is a standard practice to protect the client's privacy and maintain hygiene. Elevating the casted leg on two pillows helps reduce swelling and promote circulation, making it a suitable action.