Nokea
A 45-year-old client had a complete abdominal hysterectomy with bilateral salpingo-oophorectomy 2 days ago. The client's abdominal dressing is dry and intact. In addition, the client is taking liquids and voiding a sufficient quantity of straw-colored urine. While sitting up in the chair after her bath, the client complains of severe pain and numbness in her left leg. The nurse should respond immediately by:
- A. Administering pain medication
- B. Assessing for edema in the left leg
- C. Assessing color and temperature of the left leg
- D. Encouraging the client to change her position
Correct Answer: C
Rationale: Severe pain and numbness post-hysterectomy suggest possible deep vein thrombosis (DVT) or arterial occlusion, common postoperative complications. Assessing color and temperature of the leg (e.g., pallor, coolness) helps identify circulatory compromise. Pain medication, edema assessment, or position change are less urgent.
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A client who has been diagnosed with renal calculi reports that the pain is intermittent and less colicky. Which of the following nursing actions is most important at this time?
- A. Report hematuria to the physician.
- B. Strain the urine carefully.
- C. Administer meperidine (Demerol) every 3 hours.
- D. Apply warm compresses to the flank area.
Correct Answer: B
Rationale: Straining urine is critical when pain becomes intermittent, indicating possible stone passage, to confirm stone expulsion and guide treatment.
After the nurse has administered droperidol (Inapsine), care is taken to move the client slowly based on the knowledge of droperidol's effect on the:
- A. Central nervous system.
- B. Respiratory system.
- C. Cardiovascular system.
- D. Psychoneurologic system.
Correct Answer: C
Rationale: Droperidol can cause hypotension and orthostatic changes, affecting the cardiovascular system. Slow movement prevents dizziness or falls due to these effects.
An overweight client taking warfarin (Coumadin) has a nursing diagnosis of ineffective tissue perfusion related to decreased arterial blood flow. What should the nurse instruct the client to do? Select all that apply.
- A. Apply lanolin or petroleum jelly to intact skin
- B. Encourage a reduced-calorie, reduced-fat diet
- C. Inspect the involved areas daily for new ulcerations
- D. Instruct the client to limit activities of daily living (ADLs)
- E. Use an electric razor to shave
Correct Answer: B,C,E
Rationale: Rationales: B) A reduced-calorie, reduced-fat diet helps manage weight and reduce atherosclerosis progression, improving arterial blood flow. C) Daily inspection for ulcerations is essential in PVD to detect early skin breakdown due to poor perfusion. E) Using an electric razor minimizes the risk of cuts and bleeding, which is critical for a client on warfarin. A) Applying lanolin or petroleum jelly is not directly related to improving tissue perfusion. D) Limiting ADLs is incorrect, as moderate activity promotes circulation unless contraindicated.
A client arrives from surgery to the postanesthesia care unit. Which of the following respiratory assessments should the nurse complete first?
- A. Oxygen saturation.
- B. Respiratory rate.
- C. Breath sounds.
- D. Airway flow.
Correct Answer: A
Rationale: Oxygen saturation is the first respiratory assessment in the PACU, as it quickly indicates oxygenation status and guides further interventions if hypoxia is detected.
A 40-year-old female is losing most of her hair as a result of chemotherapy. Which of the following statements best explains chemotherapy-induced alopecia?
- A. The new growth of hair will be gray.
- B. The hair loss is temporary.
- C. A new hair growth will always be the same texture and color as it was before chemotherapy.
- D. The client should avoid use of wigs when possible.
Correct Answer: B
Rationale: Chemotherapy-induced alopecia is temporary, with hair typically regrowing within months after treatment ends, which is a reassuring and accurate explanation.