Nokea
A client has a repair of a hiatal hernia using a thoracic approach. During the immediate post-op period, the nurse should carefully assess the client for:
- A. A change in appetite
- B. Respiratory change
- C. Anxiety
- D. Activity intolerance
Correct Answer: B
Rationale: A thoracic approach affects the chest, so respiratory changes (e.g., distress, decreased oxygen saturation) are critical to assess post-op. Appetite, anxiety, and activity intolerance are less immediate concerns.
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The nurse is caring for a client who is postoperative day 1 after a total knee replacement. Which of the following actions should the nurse prioritize?
- A. Encourage use of the incentive spirometer.
- B. Administer pain medication as needed.
- C. Apply a continuous passive motion (CPM) machine.
- D. Check the surgical dressing for drainage.
Correct Answer: C
Rationale: Applying the CPM machine prevents stiffness and promotes mobility post-knee replacement. Options A, B, and D are secondary.
A Miller-Abbott tube is ordered for a client. The nurse knows that the main reason this tube is inserted is to
- A. provide an avenue for nutrients to flow past an obstructed area.
- B. prevent fluid and gas accumulation in the stomach.
- C. administer drugs that can be absorbed directly from the inTest inal mucosa.
- D. remove fluid and gas from the small inTest ine.
Correct Answer: D
Rationale: Miller-Abbott tube provides for inTest inal decompression; inTest inal tube is often used for treatment of paralytic ileus
A client with a gastric ulcer is losing a significant amount of blood via the NG tube. The client's pulse is weak and thready, and she is hypotensive. A continuous irrigation of normal saline is ordered. How should the client be positioned?
- A. High Fowler's
- B. Semi-Fowler's
- C. Supine
- D. Left-side lying
Correct Answer: B
Rationale: Semi-Fowler's position helps prevent aspiration and facilitates gastric drainage in a hypotensive client with gastric bleeding.
The nurse in the outpatient clinic plans care for a 65-year-old woman with left-sided weakness due to a cerebral vascular accident (CVA). The client has a history of hypertension and osteoporosis. It is MOST important for the nurse to encourage the client to
- A. increase the amount of calcium in her daily diet.
- B. increase the amount of vitamin D in her daily diet.
- C. increase the amount of time she is exposed to sunlight.
- D. increase her activities that involve weight-bearing.
Correct Answer: D
Rationale: Weight-bearing activities stimulate bone formation, critical for osteoporosis, and improve mobility post-CVA. Options A, B, and C support bone health but are less impactful than exercise for addressing both conditions.
An alert adult who has terminal cancer says to the home care nurse, 'When the time comes for me to go, I don't want to be in pain and I don't want you to try to resuscitate me. Please promise me you won't.' How should the nurse respond?
- A. Of course, I will do as you wish.
- B. I am obligated to try and preserve life.
- C. Do you have advance directives? These need to be in your record.
- D. Be sure to tell each nurse your desires.
Correct Answer: C
Rationale: Asking about advance directives ensures the client's wishes are documented and legally binding, facilitating appropriate end-of-life care.