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A 56-year-old client who recently had a right pneumonectomy for lung cancer is admitted to the oncology unit with dyspnea and fever. The nurse should:
- A. Place the client on the left side.
- B. Position the client for postural drainage.
- C. Provide education on deep breathing exercises.
- D. Instruct the client to maintain bed rest with bathroom privileges.
Correct Answer: C
Rationale: Deep breathing exercises promote lung expansion and oxygenation, which are critical for a post-pneumonectomy client with dyspnea and fever, potentially indicating infection or compromised lung function.
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The charge nurse on a hematology/oncology unit is reviewing the policy for using abbreviations with the staff. The charge nurse should emphasize which of the following about why dangerous abbreviations need to be eliminated? Select all that apply.
- A. To ensure efficient and accurate communication.
- B. To prevent medication errors.
- C. To ensure client safety.
- D. To make it easier for clients to understand the medication orders.
- E. To make data entry into a computerized health record easier.
Correct Answer: A,B,C
Rationale: Eliminating dangerous abbreviations ensures clear communication, prevents medication errors, and enhances client safety by reducing misinterpretations. Client understanding and data entry ease are secondary benefits.
A client who has undergone abdominal or pelvic surgery. In order to prevent deep vein thrombosis (DVT), the nurse should:
- A. Restrict fluids
- B. Encourage deep breathing
- C. Assist the client to remain sedentary
- D. Use pneumatic compression stockings
Correct Answer: D
Rationale: Pneumatic compression stockings prevent DVT post-surgery by promoting venous return and reducing stasis. Restricting fluids increases viscosity, deep breathing aids respiratory function, and remaining sedentary increases DVT risk.
The nurse in the infusion center is caring for a 27-year-old male.
Item 1 of 1
• Nurses' Notes
1401: Orders received for PRBC transfusion. 20-gauge peripheral vascular access device (VAD) started right antecubital space. Blood return was observed, and was flushed with 10 mL of sodium chloride (normal saline) without resistance. The client denied any discomfort at the VAD. Sterile dressing was applied to the VAD. The client was provided verbal education regarding the potential blood transfusion reactions. The client verbalized understanding.
1430: PRBC unit retrieved from blood bank. Vital signs were obtained prior to starting blood transfusion: 99.0° F (37.2° C) P 78, RR 18, BP 130/86, pulse oximetry reading 97% on room air.
1439: Verified and checked client ID and blood product with another RN. Initiated PRBC transfusion via y-type tubing. Will remain with the client for 15 minutes to observe for any potential transfusion-related reaction.
1454: The client denied any manifestations of a transfusion reaction. Vital signs: 99.5°F (37.5°C) P 75, RR 18, BP 132/85, pulse oximetry reading 96% on room air. Increased rate of PRBC transfusion.
1520: The client alerted RN to come to their bedside, reporting pain and discomfort at their VAD. VAD was swollen and cool to the touch.
• Orders
• Infuse 1 unit of packed red blood cells
• Medical History
• Sickle cell anemia
• Depression
The nurse reviews the clinical data and prepares to take action following the 1520 nursing note entry. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition and 2 parameters the nurse should monitor to assess the client's progress.
- A. pause the transfusion and discontinue the vascular access device,discontinue the packed red blood cell transfusion and return it to the blood bank
,start a new 20-gauge vascular access device in the opposite extremity,pause the transfusion obtain an order for acetaminophen - B. febrile transfusion reaction,infiltration at the vascular access device
hemolytic transfusion reaction,circulatory overload - C. discomfort and swelling at vascular access site,hemoglobin and hematocrit,temperature,blood pressure
Correct Answer:
Rationale: The nurse should monitor the discomfort and swelling at the VAD site. Pausing the transfusion, elevating the extremity, and applying a compress should alleviate the discomfort and swelling.
The nurse will need to monitor the client's hemoglobin and hematocrit to determine the efficacy of the PRBC transfusion. Generally, one unit of PRBCs will raise the hemoglobin by 1 g/dL.
It is inappropriate for the nurse to monitor the client's temperature as it pertains to infiltration. The client's temperature is not relevant in managing infiltration.
The blood pressure does not require monitoring because it does not show evidence of circulatory overload.
The nurse administers mannitol (Osmitrol) to the client with increased intracranial pressure. Which parameter requires close monitoring?
- A. Muscle relaxation.
- B. Intake and output.
- C. Widening of the pulse pressure.
- D. Pupil dilation.
Correct Answer: B
Rationale: Mannitol is an osmotic diuretic used to reduce ICP by drawing fluid from brain tissue. Monitoring intake and output is critical to assess its effectiveness and prevent dehydration or electrolyte imbalances. Muscle relaxation, pulse pressure, and pupil dilation are not directly related to mannitol's primary effects.
The nurse will anticipate which of the following problems that can result for the older adult undergoing abdominal surgery?
- A. Uncrossed scarring.
- B. Decreased melanin and melanocytes.
- C. Decreased healing.
- D. Increased immunocompetence.
Correct Answer: C
Rationale: Older adults have slower wound healing due to reduced collagen synthesis and cellular turnover, increasing the risk of delayed recovery post-surgery.