Nokea
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.
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The nurse is aware that a 65-year-old widower whose only son is 500 miles away is at higher risk for psychosocial distress because the client:
- A. Has been successful in dealing with stress all his life.
- B. Does not have to deal with other stressors right now.
- C. Is able to use denial as a coping mechanism.
- D. Perceives he has minimal social support.
Correct Answer: D
Rationale: Minimal social support, due to being widowed and geographically isolated from his son, increases the risk of psychosocial distress in this cancer client.
The nurse is caring for a client who sustained injuries from a light bulb explosion. On assessment, the nurse notes that a piece of glass was lodged in the client's eye. The initial nursing intervention should be which of the following?
- A. Attempt to carefully remove the glass from the eye
- B. Reassure the client that everything is okay
- C. Administer a sedative for pain relief
- D. Advise the client to remain in a sitting position until a specialist arrives
Correct Answer: D
Rationale: A foreign object like glass in the eye requires specialist intervention. Keeping the client in a sitting position minimizes further damage until a specialist evaluates. Attempting removal, false reassurance, or sedation without specialist input is inappropriate.
Which of the following lipid abnormalities is a risk factor for the development of atherosclerosis and peripheral vascular disease?
- A. Low concentration of triglycerides
- B. High levels of high-density lipid (HDL) cholesterol
- C. High levels of low-density lipid (LDL) cholesterol
- D. Low levels of LDL cholesterol
Correct Answer: C
Rationale: High levels of low-density lipoprotein (LDL) cholesterol contribute to atherosclerosis by depositing cholesterol in arterial walls, leading to plaque formation and PVD. Low triglycerides, high HDL, or low LDL are protective or neutral, not risk factors.
In addition to nausea and severe flank pain, a female client with renal calculi has pain in the groin and bladder. The nurse should assess the client further for six years of:
- A. Nephritis.
- B. Referred pain.
- C. Urine retention.
- D. Additional stone formation.
Correct Answer: B
Rationale: Groin and bladder pain in renal calculi often indicate referred pain from the stone's movement or irritation along the urinary tract.
A client with a fracture develops compartment syndrome. Which of the following signs should alert the nurse to impending organ failure?
- A. A condition.
- B. Jaundice.
- C. Generalized edema.
- D. Dark, scanty urine.
Correct Answer: D
Rationale: Dark, scanty urine indicates renal failure, a potential complication of compartment syndrome due to myoglobin release.